<p>Client Name:______Date:______Guardian or caregiver filling out this form, please put your name here: ______</p><p>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.</p><p>In your words, please tell us why you are seeking services: ______</p><p>Were you referred to us by someone else? YES / NO If so, whom? ______Why did they refer you for services, what is their concern? ______</p><p>Which symptoms listed below are you experiencing? </p><p>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</p><p>(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</p><p>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)</p><p>Please share any other strengths or resources you have: ______</p><p>Are you currently having any thoughts to harm yourself or others? YES / NO If YES, please explain your current thoughts in detail: ______</p><p>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 ______</p><p>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: ______</p><p>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</p><p>SOCIAL HISTORY</p><p>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</p><p>What is your current living arrangement:  Independent Living  Homeless  Dependent Child  Supervised setting for Adults  Supervised setting for Youth</p><p>Who do you currently live with?______</p><p>How many siblings do you have? ______What is your birth order? ______</p><p>Did you meet all your developmental milestones on time (e.g. walking, talking)? YES / NO</p><p>Please list any significant childhood or recent events (there is more room to write if needed on last page) ______</p><p>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? ______</p><p>Please list your most supportive and important relationships. Are you experiencing any current problems with any of these relationships? If yes, please explain. ______</p><p>What is your race? ______Tell us about your cultural heritage, religion, spirituality, gender, sexuality, or language abilities. ______</p><p>What is your current employment status?  Employed Full Time  Employed Part Time  Inmate  Unemployed Volunteer  Homemaker  Disabled  Supported Employment  Military  Retired  Student</p><p>What is your highest education level attained ______Current School (if applicable) ______Current employment: (if applicable) ______</p><p>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</p><p>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</p><p>Have you served in the military? YES / NO If yes, which branch? ______Are you active or have you been discharged? ______</p><p>LEGAL HISTORY</p><p>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? ______</p><p>Who is your current probation / parole officer? ______</p><p>Please identify appropriate categories for prior arrests or legal charges  DV  DUI/DWAI  Other Crimes  Civil Actions DHS</p><p>Please describe prior legal charges/arrests in greater detail ______</p><p>Are there any safety concerns? YES / NO If yes, explain: ______</p><p>SUBSTANCE USE HISTORY</p><p>Age specific substance screening:  Pre-adolescent (6-12)  Adolescent (13-17)  Adult (18+)</p><p>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 </p><p>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</p><p>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</p><p>Do you feel you have developed physical tolerance to any of the above substances? YES / NO If Yes, which one(s) ______</p><p>Have you had any previous attempts at sobriety? YES / NO What helps you be successful? ______What contributes to relapse? ______</p><p>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? ______</p><p>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</p><p>MEDICAL HISTORY</p><p>Please list your current medical conditions and your current prescriptions with doses: ______</p><p>Do any of your family members have medical conditions? YES / NO If yes, please explain______</p><p>Do you smoke tobacco? YES / NO If yes, how much and how often? ______</p><p>Are you currently pregnant? YES / NO Are you receiving care for this? YES / NO</p><p>Do you have a disability? YES / NO  Developmental disability  Hearing impairment/deaf  Brain injury  Vision impairment/blind </p><p>If developmental disability:  Developmental delay  Mental retardation  Down’s syndrome</p><p>Do you receive disability? YES / NO  SSDI  SSI Reason for disability: ______</p><p>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? ______</p><p>Who is your primary doctor? ______When were you last seen? ______What were the results or recommendations from your most recent medical visit? ______</p><p>Please list any past or present mental health diagnosis you or anyone in your family have received: ______</p><p>GOALS AND HOPES</p><p>Tell us more about your STRENGTHS  Intelligence  Commonsense  Humor  Good problem solving skills  Positive Attitude  Engaging/Social  Creative  Successful at work/school  Thoughtful</p><p>Please share any other strengths you believe you have: ______</p><p>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)</p><p>Please share any other strengths you believe you have: ______</p><p>What changes do you hope to notice or achieve by attending therapy? ______</p><p>Please use this space for any other information you feel it is important for us to know. ______</p>