In Your Words, Please Tell Us Why You Are Seeking Services

Client Name:______Date:______Guardian or caregiver filling out this form, please put your name here: ______

We are honored that you have chose Heart Centered Counseling to journey with you during this time in your life. To ensure we are providing the best service possible, please fill out the following information.

In your words, please tell us why you are seeking services: ______

Were you referred to us by someone else? YES / NO If so, whom? ______Why did they refer you for services, what is their concern? ______

Which symptoms listed below are you experiencing?

ANXIETY PANIC DEPRESSION MANIA  Agitation  Heart palpitations  Lack of interest  Grandiose thinking  Excessive worry  Sweating  Agitation  Decreased sleep  Fatigue  Trembling  Appetite change  Rapid speech  Irritability  Shortness of breath  Excessive guilt  Racing thoughts  Nightmares  Choking  Fatigue  Increased energy  Restlessness  Chest Pain  Low self-esteem  Irritability  Sleep problems  Nausea  Insomnia  Euphoria  Tension  Dizziness  Hopelessness  Impulsive choices  Poor concentration  Fear of losing control  Slowed  High risk  Dissociation  Fear of dying movements behaviors  Phobias  Numbness  Suicidal thoughts  Chills or hot flashes  Weight change  Agoraphobia

(Symptoms continued on next page) EATING BEHAVIORAL ABUSE/TRAUMA DELUSIONS  Fear of weight gain  Unruly conduct  Experienced a  Grandiose delusions  Distorted body  Impulse control traumatic event  Religious delusions image problems  Feel as if you are  Paranoid delusions  Amenorrhea  Aggressive tendencies reliving the  Somatic delusions (absence of  Attachment issues trauma  Self-depreciative delusions menstruation)  Property Damage  Avoiding  Persecutory delusions  Binge eating  Stealing reminders of  Self-induced  Self-injurious trauma HALLUCINATIONS vomiting behaviors/gestures  Feeling numb  Auditory hallucinations  Laxative abuse  Fire setting  Increased arousal  Olfactory hallucinations  Diuretic abuse  Hostility/Defiance  Tactile hallucinations  Excessive Exercise  Disproportionate Anger LEARNING  Visual hallucinations  Fasting  Assaultive toward  Problems w/  Over-eating others verbal  Weight gain  Encopresis or Enuresis expression  Weight loss  Hyperactivity  Poor reading comprehension  Poor Attention  Non-attendance

What strengths and resources do you recognize within yourself:  Intelligence  Commonsense  Humor  Good problem solving skills  Positive Attitude  Engaging/Social  Creative  Successful at work/school  Thoughtful  Supportive Family  Supportive Friends  AA/NA Support  Financial Resources  DHS Involvement  Church  Parole Involvement  Probation Involvement  Community (Other)

Please share any other strengths or resources you have: ______

Are you currently having any thoughts to harm yourself or others? YES / NO If YES, please explain your current thoughts in detail: ______

Please select any which you’ve experienced past or present:  Legal Convictions  Legal/Incarcerations  Family Substance Abuse  Suicide Attempts  Danger to Self  Fire Setting  Animal Cruelty  Sexual Misconduct  Violent Environment  Trauma  Family Mental Illness  Prenatal AOD exposure  Destruction of Property Have you ever participated in counseling before? YES / NO If so, which type:  Inpatient  Outpatient  Other ______If “yes” please indicate date, location and the reason for seeking treatment ______

How many times in your life have you: 1) Been in treatment for alcohol or drug related issues: ______2) Been hospitalized in a psychiatric facility: ______3) Been admitted to a detox facility: ______

In the last 6 months, have you been admitted to a psychiatric facility? YES / NO In the last 6 months have you been to the ER for any psychiatric reason? YES / NO

SOCIAL HISTORY

Are you Married? YES / NO Do you have children? YES / NO How many children and what are their ages? ______Are you experiencing any marital problems? YES / NO Do you have safety concerns? YES / NO

What is your current living arrangement:  Independent Living  Homeless  Dependent Child  Supervised setting for Adults  Supervised setting for Youth

Who do you currently live with?______

How many siblings do you have? ______What is your birth order? ______

Did you meet all your developmental milestones on time (e.g. walking, talking)? YES / NO

Please list any significant childhood or recent events (there is more room to write if needed on last page) ______

Have you experienced any physical, sexual, or emotional abuse in the past or present? YES / NO If comfortable, please explain ______Are you experiencing any problems with day to day functioning as a result of your current issues? ______

Please list your most supportive and important relationships. Are you experiencing any current problems with any of these relationships? If yes, please explain. ______

What is your race? ______Tell us about your cultural heritage, religion, spirituality, gender, sexuality, or language abilities. ______

What is your current employment status?  Employed Full Time  Employed Part Time  Inmate  Unemployed Volunteer  Homemaker  Disabled  Supported Employment  Military  Retired  Student

What is your highest education level attained ______Current School (if applicable) ______Current employment: (if applicable) ______

Are you experiencing any current school or work related issues? YES / NO  Difficulty finding a job  Tardiness  Conflict with peers  Job loss  Substance use at work/school  Attendance  Behavior issues  Attention issues  Conflict with teacher/supervisor  Performance Issues Difficulty keeping a job  Spotty work Hx

Are there positive aspects about school or work?  Enjoys current job/school  Successful  Works well with others  Proud of accomplishments  Excelling  A leader  Consistently good grades  Improved grades  Recent promotion

Have you served in the military? YES / NO If yes, which branch? ______Are you active or have you been discharged? ______

LEGAL HISTORY

Do you have a history of civil or criminal legal involvement? YES / NO In last 30 days, how many DUI or DWAI arrests have you had? ______In the last 30 days, how many “other” arrests have you had? ______

Who is your current probation / parole officer? ______

Please identify appropriate categories for prior arrests or legal charges  DV  DUI/DWAI  Other Crimes  Civil Actions DHS

Please describe prior legal charges/arrests in greater detail ______

Are there any safety concerns? YES / NO If yes, explain: ______

SUBSTANCE USE HISTORY

Age specific substance screening:  Pre-adolescent (6-12)  Adolescent (13-17)  Adult (18+)

Pre-Adolescent: Has the child been exposed to alcohol, tobacco, or drugs? YES / NO  Prenatal exposure to alcohol  Accidental exposure to alcohol  Alcohol intoxication at least 1x  Prenatal exposure to drugs  Accidental exposure to drugs  Drug intoxication at least 1x  Drug addicted at birth  Regular use of tobacco  Drug exposed at birth  Alcohol use  Drug use  Tobacco use

Adolescent: Have you ever ridden in a CAR driven by someone; including you who was high/drunk or using? YES / NO Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in? YES / NO Do you ever FORGET things you did while using alcohol or drugs? YES / NO Do your FAMILY/FRIENDS ever tell you that you should cut down on drinking or drug use? YES / NO Have you ever gotten into TROUBLE while you were using drugs or alcohol? YES / NO Adult: Have you ever felt you should CUT down on your drinking or drug use? YES / NO Have you ever felt bad or GUILTY about your drinking or drug use? YES / NO Have people ANNOYED you by criticizing your drinking or drug use? YES / NO Have you ever drank/used drugs EARLY in morning to steady nerves or get rid of a hangover? YES / NO

Type of Substance Age you # of times # of times Quantity How Route used When began you used you used you use often (oral, nasal, did you using in last 30 in your each time do you smoking, last days lifetime use IV) use? Alcohol Heroin Methamphetamine Cocaine THC Other Amphetamines Opiates Barbiturates Other Other

Do you feel you have developed physical tolerance to any of the above substances? YES / NO If Yes, which one(s) ______

Have you had any previous attempts at sobriety? YES / NO What helps you be successful? ______What contributes to relapse? ______

Have you participated in Substance Abuse/Dependence Treatment in the past? YES / NO If yes, please explain______Is there family history of addiction?  None  Alcoholism  Drug Abuse If so, who in your family and what was their drug of choice? ______

In last 30 days, how much money have you spent on alcohol or drugs? ______In the last 30 days, how many days have you been bothered by substances? ______In the last 30 days, how many times have you attended AA or NA (self-help)? ______In the last 30 days, have you been through detox? YES / NO

MEDICAL HISTORY

Please list your current medical conditions and your current prescriptions with doses: ______

Do any of your family members have medical conditions? YES / NO If yes, please explain______

Do you smoke tobacco? YES / NO If yes, how much and how often? ______

Are you currently pregnant? YES / NO Are you receiving care for this? YES / NO

Do you have a disability? YES / NO  Developmental disability  Hearing impairment/deaf  Brain injury  Vision impairment/blind

If developmental disability:  Developmental delay  Mental retardation  Down’s syndrome

Do you receive disability? YES / NO  SSDI  SSI Reason for disability: ______

In the last 6 months, how many times have you visited the Emergency Room for medical reasons? ______In the last 6 months, how many times have you been admitted to a medical hospital? ______

Who is your primary doctor? ______When were you last seen? ______What were the results or recommendations from your most recent medical visit? ______

Please list any past or present mental health diagnosis you or anyone in your family have received: ______

GOALS AND HOPES

Tell us more about your STRENGTHS  Intelligence  Commonsense  Humor  Good problem solving skills  Positive Attitude  Engaging/Social  Creative  Successful at work/school  Thoughtful

Please share any other strengths you believe you have: ______

Tell us about the RESOURCES you currently have  Supportive Family  Supportive Friends  AA/NA Support  Financial Resources  DHS Involvement  Church  Parole Involvement  Probation Involvement  Community (Other)

Please share any other strengths you believe you have: ______

What changes do you hope to notice or achieve by attending therapy? ______

Please use this space for any other information you feel it is important for us to know. ______