Northeastern Professional Counseling

NewClientForm ( Adult ) Date: Instructions: Pleasecompletethis formto the best of yourability with theinformationyouhaveavailableto youat this time. Doyourbest to answereachitemas fully as youcan . General ClientInformation Name: ( First , Middle , Last ) Gender: Age : DOB : Soc #: Address City State: Zip code : HomePhone : Cell: Mayweleaveyoua voicemessage? YES NO Email address : (pleasebe awareemail is nonsecure - ) Placeof Birth : EthnicCultural/ Background : Religion : NativeLanguage : Marital Status : Education ( highest degreegradelevel/ / ): Occupation : AnnualIncome : Employer : EmergencyContact : Relationship: Phone:

Referredby : MayI thankthis referral sourcefor directingyouto this practice? Yes No

HealthInsuranceInformation InsuranceCompany : Policy #: Group #: CoPay :

Nameof Subscriber : Date of Birth of Subscriber : Relationto Client :

Placeof Employmentof Subscriber :

CurrentIssues Pleaseprovidea brief descriptionof whyyouare seekingcounselingtherapyservicesat / this time :

 Hasanythinghappenedthat mayhavebroughtonintensifiedthe / problemsyouare experiencing? Yes No If yes , pleaseexplain :  When ( monthyear / ) did youfirst beginto experiencetheseproblems?  Howmanydays , weeks , months , or years haveyoubeenexperiencingtheseproblems?  Howoftendoyouexperiencetheseproblems? ( checkthe onethat best describesyourcurrentexperience ). Most of the day , every day Somepart of the day , everyday Most of the day on most days Somepart of the day on most Days Northeastern Professional Counseling

Morethanoncea week Morethanoncea month Other: Northeastern Professional Counseling

 Howmuchisare / the problemsaffectingyou? Mildly Moderately Severely  In what areasdo yourproblemsimpactyourlife? ( Checkall that apply ) Lifestyle ( the wayyoulive yourlife ) Activities ( thingsyounormallydo or wouldlike to do ) Relationships ( your ability to formor maintainrelationshipswith others ) Sleeping Mood  Haveyouever attemptedsuicide? Yes No If yes , when?  Haveyoubeenthinkingaboutsuicide? Yes No  Haveyouever thoughtaboutharmingor killingsomeoneelse? Yes No If yes , when?  Haveyoubeenthinkingaboutharmingor killingsomeoneelse? Yes No Adult ProblemsChecklist Instructions: Please check all that apply to you

Emotional Issues: Weight problems mistrustfulness Self injurious Depression Appetite changes behaviors Anxiety/tension/worry (more/less) Delusions/hallucinations Job/career problems or Stress Sleep changes Confusion/can’t think indecision Anger/frustration (more/less) clearly Financial problems Loneliness Bad Losing track of time Stealing Feeling Ignored or dreams/nightmares Problems with Use of alcohol abandoned Chills/hot flashes memory Use of drugs Mood swings Tingling/numbness Unpleasant thoughts Blackouts Lack of Nausea that Trouble with the law interest/enjoyment Pain won’t go away Destruction of in life Health problems Bothered by recurring property Feeling hopeless Feeling “not real” thoughts Strange, weird, or Feeling worthless Feeling detached from Behavioral Issues: peculiar Feeling guilty yourself Isolating from behavior Feeling shameful Thought Issues: others/social Performing unusual Feelings of Poor concentration withdrawal ritual or sadness/loss Fear of dying Disorganization habits Easily Fear of going “crazy” Aggressiveness irritated/annoyed Fears or phobias Perfectionist behavior Relational Issues: Grief/bereavement Lying Family problems Feeling “hyper” Obsessions/compulsions Procrastination Marital/relationship Bodily Issues: Thoughts racing Impulsiveness problems Low energy Low self-esteem Excessive behaviors Parent/child problems Panic attacks Self-criticism (Examples: spending, Problems trusting Chest pain or Can’t hold onto an gambling, sex, others heaviness idea alcohol) Loss/death of Heart racing Suspiciousness or someone Northeastern Professional Counseling

close No/lack of social others Making/keeping support Trauma: Experienced/witnessed friends (family/friends) Physical abuse trauma Arguing with others Sexual problems Sexual abuse Other (please Shyness Your problems Partner abuse describe): Social skills impacting CurrentLife Experiences  I live in : Apartment House CondoTownhouse / Mobile Home RoomingHouse Other

Persons( ) Livingin your home AGE SignificantIssues

 Othersignificantpersonsin mylife whodonot live with meinclude : Name Age RelationshipProblems /

 Problemsor changesin myfamily or otherimportantinterpersonalrelationships : Dates( ) PersonsInvolved Problemsor Changes

 Problemsor changesin occupational , educational , social , or recreationalfunctioning : Dates( ) Wheredid this occur? Problemsor Changes

 What makesyoufeel goodaboutyourself at the endof a day :

 What weighson yourminda lot :

 What doyoudoto relaxhavefun / :

 Doyouhaveanycurrentlongtermgoals / :

 What I hopeto gain fromcounselingtherapy / :

 Mytypical dayis as follows :

Historyof Counselingor / Therapy  Are you currently beingtreatedby a counselor , psychologist , or psychiatrist? Yes No If yes , pleaseprovidethe followinginformation : Dates( ) Nameof Professional TreatmentType ( counseling , therapy , medication , etc .)

 Pleaseprovideinformationregarding previous treatmentyouhavereceivedfroma counselor , psychologist , psychiatrist , or othermedical or mental healthprofessionalfor this or otherproblems : Dates( ) Nameof Professional TreatmentType Whytreatmentended

 Haveyouever beenhospitalizedfor treatmentof an emotionalor mental disorder? Yes No If yes , pleaseprovidethe followinginformation : Dates( ) Nameof Hospital or Facility Reasonfor Hospitalization

Northeastern Professional Counseling

MedicalHistory  Pleasecompletetheinformationbelowregarding past andcurrent medical conditionsandtreatment :

Dates( ) PhysicianName Condition TreatmentResults /

 Pleaselist anyhospitalizationsor surgeries : Dates( ) HospitalFacility / ConditionTypeTreatment/

 Pleaselist all current prescriptionandoverthecountermedicationuse : BeginDate : MedicationDose / Frequencyof use ConditionTreated

 Pleaselist any previous prescriptionandover the countermedicationuse significantto yourcounselingtherapy / : Dates( ) MedicationDose / Frequencyof use ConditionTreated From: To : From: To : From: To : From: To : From: To : From: To : Northeastern Professional Counseling

 Pleaselist anyallergiessensitivitiesdrugreactions / / :

CurrentHistoryof/ DrugUse

Ever Substance Ageof 1st PertinentInformation - i. e . frequencyof UseCurrentPast / / Used? Use Y N Tobacco: Smoking Chewing Y N Alcohol

Y N PrescriptionDrugs

Y N Marijuana

Y N CocaineCrack/

Y N Heroin, speedball

Y N Methamphetamine

Y N Sedativesor tranquilizers (downers ) Y N Stimulants (uppers , speed , ice)

Y N Hallucinogens (PCP , angel dust, ecstasy , mushrooms , LSD) Y N Sniffedor inhaled anything to get high ( poppers , sprays, glue ) Northeastern Professional Counseling

Y N Other: Northeastern Professional Counseling

Familyof Origin

 Pleasedescribethe backgroundor statusof yourfamily of origin for the followingcategories :

Ethnic: Social: Religious: Financial:

 Briefly describeanyof thefollowingthat apply to yourfamily of origin :

 Crisis or othersignificantevents :

 Anyemotional , psychological , or physical illness : ( Examples : cancer , diabetes , heart disease , depression , alcoholism, drugabuseor addiction , family violence , depression , suicide )  Communicationstylesin yourfamily of origin? Whodid most of the talking , teaching , andconnecting?

 PleaseDescribepast andcurrentrelationshipwith :

Mother:

Father:

Stepparent: or NA /

Siblings: or NA /

Othersignificantfamily members : Northeastern Professional Counseling

For OfficeUseOnly :

DiagnosisandSummary Includingcooccurringdisordersor - relevantmedicaldiagnoses Code Type Description Number Principal ( P ) or Additional ( A ) P A P A P A P A P A ------

Typesof Problems : Primarysupportgroup Social environment Educational Occupational Housing Economic Accessto healthcare services Interactionwith legal systemcrime / Otherpsychosocialand environmentalproblems : GAFScore :

Clinical SummaryInitial / Impressions :

SignatureCredentials/ : ______Date: ______