Phone: Fax: website:
|
|
|
- Isaac Walters
- 8 years ago
- Views:
Transcription
1 Hope in Healing Counseling and Wellness, LLC Stacy Nunne, MA, LAMFT, RN KleinBank Building Mailing Address: PO Box West 78th Street, Suite 10B Chanhassen, MN Chanhassen, MN Phone: Fax: website: Adolescent Psychotherapy Intake To be Completed by Adolescent This form is intended to help your counselor become better acquainted with you and in turn, serve you better. You may omit any item, but try to be as thorough as possible. Please use the back if you need more space. Thank you. Client Name: Nickname: Date: Date of Birth: Age: Gender: Male Female Grade in school: What brings you to therapy?: My current concerns/symptoms developed (Please Circle): Suddenly (less than four weeks) Gradually (one to several months) Very Gradually (one to several years) How would you describe your mood at this time?: What would you like to see change as a result of therapy? Have there been any significant changes in your life recently? Yes No If yes, please describe: What do you hope that will be different in your life as a result of coming to therapy?: Do you have any concerns at this time about hurting yourself? No Yes If yes, please describe: Do you have any concerns at this time about hurting someone else? No Yes If yes, please describe: Family Environment/Relationships Your Living Situation I live with: Biological Parents Adoptive Parents Parent and Step-Parent Foster Parents One Parent Alone Relatives Other: Primary Household Household Age Relationship Describe Relationship Member Name to me Do you live in more than one household? No Yes If no, skip to Secondary Household. If yes, complete the secondary household information. Hope in Healing Counseling and Wellness, LLC, Adolescent Psychotherapy Intake (revised ) Page 1 of 6
2 Secondary Household Household Age Relationship Describe Relationship Member Name to me Additional family members living with you Household Age Relationship Describe Relationship Member Name to me How would you describe your family?: What does your family do together?: Describe how problems are generally handled in your family?: Where did you live growing up? (Please list all places): Have you experienced a death (family, friends, pets, etc.)? No Yes At what age(s)? If yes, please describe your reaction: Development History Are there special, unusual, or traumatic circumstances that affected your development? No Yes If yes, please describe: Do you have a history of abuse? No Yes If yes, which type(s): Sexual Physical Verbal Emotional Neglect Inadequate Nutrition Inadequate Medical Attention Inadequate Dental Attention Is there anything else that happened to you that you consider abuse?: Did anyone in your family of origin experience childhood abuse? No Yes If yes, Whom: Mental Health Treatment History Have you experienced or witnessed any of the following? No Yes (Please check all that apply to you) Car accident Community violence Bullying Domestic violence/abuse Other accident Fire Natural disasters Significant loss Physical illness Relationship Abuse Recent Death Loss of friendships Other: Hope in Healing Counseling and Wellness, LLC, Adolescent Psychotherapy Intake (revised ) Page 2 of 6
3 Behavioral/Emotional Health (Please check all of the following that apply to you): Affectionate Expect Failure Moody Slow Moving Aggressive Fatigued Neat/Orderly Speech Problems Anger Problems Fearful Nightmares Steal Anxiety Fearless Overweight Stomachaches Argue Excessively Frequent Injuries Phobias Stutter Avoids Adults Frustrated Daily Preoccupied with Things Teeth Grinding Bully/Threaten Others Generous Quiet or Withdrawn Tics or Twitching Careless/Reckless Have Bad Dreams Sad Tired Often Clumsy Hopelessness Selfish Underweight Confident Impulsive Self-Mutilation Unsafe Behaviors Cooperative Irritable Separation Anxiety Unusual Thinking Depressed Lazy Set Fires Withdrawn Destructive Learning Problems Short Attention Span Worry Excessively Difficulty Speaking Loner Shy/Timid Other Defiant Low Self-Esteem Sick Often Other Enthusiastic Messy Sleeping Problems Other Please describe any of the above or any other concerns: Alcohol or Drug/Chemical Use - Please list the alcohol or drugs/chemicals that you have used - list how much: Never Used Used in the Past Age Started Daily Weekly Occasionally Last Use Caffeine Tobacco Alcohol Marijuana/THC Cocaine/Crack Inhalants/ Huffing LSD/ Shrooms Prescribed Pills Heroine Speed, Ecstasy Rohypnol-Roofies GHB-liquid ecstasy LSD Steroids Others: Others: If you use alcohol or Drugs/Chemicals: Do you have any concerns about your use of alcohol? No Yes Drugs/Chemicals? No Yes Do you believe that you have a problem with alcohol? No Yes Drugs/Chemicals? No Yes If yes, how long have you gone without using alcohol or drugs/chemicals? Are others concerned about your alcohol use? No Yes Drugs/Chemical use? No Yes Whom? Hope in Healing Counseling and Wellness, LLC, Adolescent Psychotherapy Intake (revised ) Page 3 of 6
4 Have you ever been in treatment for alcohol or chemical dependency? No Yes If yes, where? Treatment Center/Hospital (Include inpatient, outpatient, detox) Dates Did you learn anything that was helpful? No Yes Please describe what you found to be helpful: Are you currently seeing a psychiatrist? No Yes Psychiatrist: Is he/she helpful?: Have you ever been hospitalized for psychiatric reasons? No Yes Hospital Reason for Hospitalization Dates Have you ever been under the care of a therapist? No Yes If so, with who and when? Therapist Approximate Dates Helpful? Is there a family history of a problem with alcohol? No Yes Drugs/Chemicals? No Yes Please indicate A-alcohol D- Drugs/Chemicals Mother Father Sibling Maternal Grandmother Paternal Grandmother Sibling Maternal Grandfather Paternal Grandfather Sibling Maternal Aunt Paternal Aunts Other Maternal Uncle Paternal Uncles Other General Health Information (Please put C-Current and/or P-Past for all that apply to you): Abdominal pain Diabetes Headaches Skin Problem ADHD Disability Heart trouble Sleeping Problems Allergies Dizziness Memory Impairment Speech Problems Asthma Excessive Sweating Migraines Stomach Trouble Neck/Back pain Eye Problems Numbness/Tingling Tics/Tremors Blackouts Fainting Spells Pain-Where? Wears glasses Chest Pains Fatigue Respiratory illness Other Colds/Coughs Hearing Loss Seizures Other Dental problems Head Injury Severe Head Injury Other Please list any current health concerns or problems OR any changes in your health?: Have you ever had any seizures or head injuries? No Yes If yes, please describe: Please check if you have noticed/experienced any recent changes in the following: Sleep patterns Eating patterns Behavior Energy level Physical activity level General disposition Weight Nervousness/tension Please describe: Hope in Healing Counseling and Wellness, LLC, Adolescent Psychotherapy Intake (revised ) Page 4 of 6
5 Sexual History Are you currently sexually active? No Yes Have you been sexually active in the past? No Yes Do you have any concerns about your sexual development? No Yes Please explain: Education Current school: How long attended?: Type of school: Public Private Home schooled Other (please specify): Grade: Teacher: School Counselor: Previous Schools: Do you have any learning problems?: Which subject/areas interest you the most in school?: Which subject/areas interest you the least in school?: What grades do you typically receive in school?: Have there been any changes in your grades? No Yes If yes, please describe: Performance in school (by your report): Satisfactory Underachieve Overachieve Please check below the words that best describe you in regards to school performance: Anxious Disorganized Interested Responsible Bored Eager Lack of Initiative Self-Directed Cooperative Enthusiastic Organized Sloppy Disinterested Industrious Passive Does only what is expected Other (please describe): Do you have any problems with teachers or other classmates? No Yes If yes, please describe: Please check below the words that best describe your peer relationships: Spontaneous Follower Leader Have Difficulty Making Friends Have Few Friends Have a Lot of Friends Make Friends Easily Have Long-Time Friends Have a Few Good Friends Other (please describe): Please describe your friendships: Culture/Ethnicity To which cultural or ethnic group, if any, do you consider you belong?: Are you experiencing any problems due to cultural or ethnic issues? No Yes If yes, please describe: Is there any other cultural/ethnic information you want your therapist to know? Spiritual/Religious How important are spiritual matters to you? Not at all A little Somewhat Very Are you affiliated with a spiritual or religious group? No Yes If yes, please describe: Hope in Healing Counseling and Wellness, LLC, Adolescent Psychotherapy Intake (revised ) Page 5 of 6
6 Is your family affiliated with a spiritual or religious group? No Yes If yes, please describe: Would you like your spiritual/religious beliefs included in counseling? No Yes If yes, please describe: Internet How much time do you spend on the internet/phone/ipod/video games a day?: hours Does media use interfere with school work? Yes No Job? No Yes Family time? No Yes Friendships? No Yes Extra-curricular activities? No Yes Leisure/Recreational Please describe your family s areas of interests or hobbies that you do together: Please describe your areas of interest or hobbies (e.g., art, books, bowling, church activities, crafts, fishing, hunting outdoor activities, school activities, school clubs, school sports, scouts sports (outside of school), working out, etc.) Activity How often I How often I have participate? participated in the past? Current Employment Status Do you have a job? No Yes Full Time Part Time Where? Do you have any concerns about your work environment? No Yes Please explain: Legal History Do you have a history of legal charges? No Yes If so, please describe Do you have involvement with any of the following people or services? No Yes If yes, please circle all that apply: County Social Worker Probation Officer Adult/Child Protection Guardian Ad Litum If so, please describe: Additional Personal Information Is there any additional information that you believe would help me in understanding you?: Is there any additional information that would help me understand your current concerns or problems?: Is there anything else that you would like me to know about your family?: What are your goals for therapy? Is there anything else that you think would help you to have a positive therapy experience?: Client Signature: Date: Hope in Healing Counseling and Wellness, LLC, Adolescent Psychotherapy Intake (revised ) Page 6 of 6
Marisa Nava, Ph.D. Licensed Clinical Psychologist Personal History Children and Adolescents (<18)
Marisa Nava, Ph.D. Licensed Clinical Psychologist Personal History Children and Adolescents (
Adult Information Form Page 1
Adult Information Form Page 1 Client Name: Age: DOB: Date: Address: City: State: Zip: Home Phone: ( ) OK to leave message? Yes No Work Phone: ( ) OK to leave message? Yes No Current Employer (or school
OK to leave Messages?
Jami Howell, Psy.D., LLC Licensed Clinical Psychologist 1215 SW 18 th Avenue, Portland OR 97205 p (503) 504-5222 f (503) 224-2134 jami@doctorjamihowell.com Client Information Name: Preferred Name: Date
Santa Fe Sage Counseling Center
Couple/Family Client Intake Date: Names: Partner/Parent/Child (circle one) Partner/Parent/Child (circle one) Parent/Child (circle one) Parent/Child (circle one) Parent/Child (circle one) Insurance ID #:
Thelma F. Lynch, RN, PH.D Psychologist Children, Adolescents, Adults. Child/Adolescent Psychosocial
Thelma F. Lynch, RN, PH.D Psychologist Children, Adolescents, Adults 1806 Town Plaza Ct. Winter Springs, FL 32708 407-850-8875 Fax: 407-695-3674 Child/Adolescent Psychosocial Identifying Information: Name
General Information. Age: Date of Birth: Gender (circle one) Male Female. Address: City: State: Zip Code: Telephone Numbers: (day) (evening)
Kelly Bernstein, MS, LCDC, LPC Medical Center Psychological Services 7272 Wurzbach Road, Suite 1504 San Antonio, Texas 78240 Office: (210) 522-1187 Fax: (210) 647-7805 Functional Assessment Tool The purpose
Atlanta Center For Positive Change Karen Kallis, M.Ed., LAPC, NCC 333 Sandy Springs Circle, Atlanta, GA 30328
Atlanta Center For Positive Change Karen Kallis, M.Ed., LAPC, NCC 333 Sandy Springs Circle, Atlanta, GA 30328 An important part of the helping relationship is understanding the expectations of the relationship.
Dr. John Carosso, Psy.D Psychologist Autism Center of Pittsburgh
Dr. John Carosso, Psy.D Psychologist Autism Center of Pittsburgh Evaluation Date: Client Information Child s Name: Date of Birth: Age: Male Female Eye Color Ethnicity: Insurance: Primary _ ID # Grp # Card
Intake Form. Marital Status: Date of Birth: Street Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Social Security #:
Intake Form PATIENT INFORMATION Patient Last Name: First Name: Marital Status: Date of Birth: Street Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Social Security #: Gender: Employer:
Family Counseling Center Children s Questionnaire (to age 10) For Parent/Guardian to Complete. Child s Name: DOB: Age:
Family Counseling Center Children s Questionnaire (to age 10) For Parent/Guardian to Complete Child s Name: DOB: Age: School: Grade: Race/Ethnic Origin: Religious Preference: Family Members and Other Persons
Intake Form for Testing Services. Last Name First Name Date of Birth. Address City State/ZIP Sex (M/F)
Intake Form for Testing Services Date Last Name First Name Date of Birth Address City State/ZIP Sex (M/F) Email Address: @ CAN I EMAIL YOU FOR: (CIRCLE ALL THAT APPLY) SCHEDULING SERVICES UPDATES AVAILABLE
PARTNERS IN PEDIATRIC CARE. Intake and History for Mental Health Referral
PARTNERS IN PEDIATRIC CARE Intake and History for Mental Health Referral This form is designed to give you an opportunity to provide us with background information that will help us help you. Please read
Megan Ogle, PsyD Clinical Psychologist 1215 SW 18 th Avenue, Portland, OR 97205 971.313.4518 dr.meganogle@gmail.com
Megan Ogle, PsyD Clinical Psychologist 1215 SW 18 th Avenue, Portland, OR 97205 971.313.4518 dr.meganogle@gmail.com Client Information Date: Name: Preferred First Name: Date of Birth: / / SSN: - - Address:
Behavioral and Developmental Referral Center
Dear Parent, Thank you for allowing us the opportunity to serve your family. We will make every effort to best meet your needs. You will find a brief questionnaire enclosed with this letter. This information
SOCIAL AND DEVELOPMENTAL HISTORY. School Attending: Grade: Date of Birth: Telephone: Home: Work: Cell:
SOCIAL AND DEVELOPMENTAL HISTORY Student s Name: First Middle Last Male Female School Attending: Grade: Date of Birth: Parent s Names: Address: Telephone: Home: Work: Cell: Parent email address: Legal
New Venture Christian Fellowship Therapy Introduction to Individual Counseling
New Venture Christian Fellowship Therapy Introduction to Individual Counseling Welcome to counseling. We look forward to meeting with you and getting started. People and their situations are often very
1 Central 601 West Second Street, Bloomington, IN 47402 t 812.353.9484 800.934.6074
Locations 1 Central 601 West Second Street, Bloomington, IN 47402 t 812.353.9484 800.934.6074 2 East 328 S. Woodcrest Drive, Bloomington, IN 47401 t 812.353.3278 866.353.3278 3 West 2499 W. Cota Drive,
Arrive 15 minutes before your scheduled appointment time.
Thank you for choosing Dr. Townsend and Associates, P.A. for your counseling and evaluation needs. We respect your time and would like to provide you with a full 45 minute session. In order for your therapist
Client Initial Interview Form. Address: City: State: Zip: Phone: (h) (C) May I leave messages at these phone numbers? yes no
Nancy Thomas, M.A., LPC-Intern Supervised by Jennifer Perla, LPC-S The Vale Counseling and Therapeutic Center 2862 N. Belt Line Road, Sunnyvale, TX 75182 www.nancythomascounseling.com Office: (972) 698-8478
Behavioral Health Consulting Services, LLC
www.bhcsct.org infohealth@bhcsct.org 46 West Avon Road 322 Main St. 530 Middlebury Road Suite 202 Suite 1-G Suite 103 B Avon, CT 06001 Willimantic, CT 06226 Middlebury, CT 06762 Office phone- 1-860-673-0145
NEW PATIENT INFORMATION CONSENT AND AGREEMENT
NEW PATIENT INFORMATION CONSENT AND AGREEMENT PSYCHOLOGICAL SERVICES. Psychological services vary depending on the reason for referral. In all cases, the initial appointment is set up with the parents/guardians
Child s Legal Name: Date of Birth: Age: First, Middle, and Last Name. Nicknames: Social Security #: - - Current address: Apt #:
Parent Questionnaire Child s Legal Name: Date of Birth: Age: First, Middle, and Last Name Nicknames: Social Security #: - - Current address: Apt #: City: State: Zip Code: Home Phone: Cell/Other #: Parent
UWM Counseling and Consultation Services Intake Form
UWM Counseling and Consultation Services Intake Form Dear Student, Date Affix Label Here (Office Use Only) Thank you for giving us the opportunity to better serve you. Please help us by taking a few minutes
Easy Does It, Inc. Transitional Housing Application
Easy Does It Inc. of Reading and Leesport Housing Programs Easy Does It, Inc. Transitional Housing Application Welcome Thank you for applying to Easy Does It, Inc. ( EDI ) a non-profit charitable organization
Social Security # Date of Birth Age. Mailing Address City State Zip Code. Race Gender Height Weight Religious preference
VCU ADMISSION APPLICATION (804) 828-8822 Fax: (804) 828-9879 SERVICE REQUESTED 30-Day Evaluation 15-Day Evaluation Child s Name (please print) Nickname Social Security # Date of Birth Age Mailing CHILD
NEW PATIENT INFORMATION
NEW PATIENT INFORMATION Date Patient Name Sex Age DOB / / Address City State Zip Phone Email Emergency Contact: Relationship to patient: Phone #(s) How did you hear about my practice? RESPONSIBLE PARTY
Family Center By The Falls Parent Questionnaire
Child s Name: Preferred First Name: Family Center By The Falls Today s Date: Age: Grade: Names of Parents/Guardians: Name of School: Name of Pediatrician: Who referred you to us? Has your child been seen
Macalester Health & Wellness Center Counseling Services Page 1 Intake Data Sheet
Macalester Health & Wellness Center Counseling Services Page 1 Intake Data Sheet Date: Student s Name: Student s ID: Local Address: Residence Hall & Room Number or Local Street Address Personal Phone:
Post Traumatic Stress Disorder and Substance Abuse. Impacts ALL LEVELS of Leadership
Post Traumatic Stress Disorder and Substance Abuse Impacts ALL LEVELS of Leadership What IS Post Traumatic Stress Disorder (PTSD) PTSD is an illness which sometimes occurs after a traumatic event such
Grace Biblical Counseling Ministry
Grace Biblical Counseling Ministry Personal Data Inventory Name Address Sex: Age: Date of Birth: Phone Number: Highest Education: High School GED College Graduate Post Graduate Other Education or Training
Medicines To Treat Alcohol Use Disorder A Review of the Research for Adults
Medicines To Treat Alcohol Use Disorder A Review of the Research for Adults Is This Information Right for Me? Yes, this information is right for you if: Your doctor* said you have alcohol use disorder
Drug Abuse and Addiction
Drug Abuse and Addiction Introduction A drug is a chemical substance that can change how your body and mind work. People may abuse drugs to get high or change how they feel. Addiction is when a drug user
Methamphetamine. Like heroin, meth is a drug that is illegal in some areas of the world. Meth is a highly addictive drug.
Methamphetamine Introduction Methamphetamine is a very addictive stimulant drug. People who use it can form a strong addiction. Addiction is when a drug user can t stop taking a drug, even when he or she
PATIENT INTAKE / HISTORY FORM PATIENT INFORMATION
Mona Mikael, Psy.D., PSY 25089 Neuro- Rehabilitation Psychologist Neuro- Rehab Psychological Consultation & Treatment 630 S. Raymond Ave., #340 Pasadena, CA 91105 626-710- 7838 Web: www.neurorehabtlc.com
Cocaine. Like heroin, cocaine is a drug that is illegal in some areas of the world. Cocaine is a commonly abused drug.
Cocaine Introduction Cocaine is a powerful drug that stimulates the brain. People who use it can form a strong addiction. Addiction is when a drug user can t stop taking a drug, even when he or she wants
Glen Davis PhD Maine Child Psychology 2 Elm Street, Waterville, ME 04901 Telephone: (207) 221-2631 Fax: (207) 221-3368 MaineChildPsych.
Dear Parent, Glen Davis PhD Maine Child Psychology 2 Elm Street, Waterville, ME 04901 Telephone: (207) 221-2631 Fax: (207) 221-3368 MaineChildPsych.com Thank you for your interest in psychological services
SPOUSE / PARTNER ONE TO COMPLETE THIS SECTION SEPARATELY. Name: (Last) (First) (Middle Initial)
Katherine E. Walker, PhD, LPC, NCC, BCIA-C Licensed Professional Counselor 8300 Health Park, Suite 201 Raleigh, NC 27615 Mobile: 919-760-3068 Fax: 919-676-9946 Email: walker@carolinaperformance.net Couples
Managed Health Care Administration Initial Assessment Child/Adolescent Program Parent Questionnaire Page 1
Page 1 Date: Patient Name: Date of Birth: / / Age of Patient: Name of person completing this form Relationship to Patient: Dear Parent: The information that you provide is critical in providing an accurate
I. Each evaluator will have experience in diagnosing and treating the disease of chemical dependence.
PREVENTION/INTERVENTION CENTER COBB COUNTY PUBLIC SCHOOL SAFE AND DRUG FREE PROGRAM www.cobbk12.org/~preventionintervention CONTRACT FOR SERVICE PROVIDERS As a member of the Cobb County Schools Coalition
Occupational Therapy Intake Form
Occupational Therapy Intake Form Child s Name: Date: Age: DOB: Gender: Address: City: Zip: (cell): Phone (home): Insurance Who referred you? Primary Care Physician Address: Member ID: Phone: Fax: School
INITIAL INTAKE FOR MEGAN POLLOCK THERAPY (PLEASE COMPLETE PAGES 1 5 AND RETURN TO THERAPIST)
INITIAL INTAKE FOR MEGAN POLLOCK THERAPY (PLEASE COMPLETE PAGES 1 5 AND RETURN TO THERAPIST) Last Name: Dr. Mr. Mrs. Ms. First Name: Middle Initial: Date of Birth: Home Address: City: Zip Code: Social
Suicide Screening Tool for School Counselors
Suicide Screening Tool for School Counselors I. Risk Factors Check all that apply History of prior suicide attempts Self-injurious behaviors (past or present) Feelings of hopelessness Impulsivity Anxiety
Declaration of Practices and Procedures
Peggy S. Arcement, MS, MA, LDN, LPC, NCC Licensed Professional Counselor Baton Rouge Christian Counseling Center 763 North Boulevard, Baton Rouge, Louisiana 70802 Phone: 225-387-2287 Fax: 225-383-2722
5421 Riverbluff Parkway North Charleston, SC 29420 (843) 300-0440 counseling@riverbluff.org
Minor Child 5-12 years Client Information Packet Please take a moment to complete all of the following information. This information will assist us in getting to know you and what prompted you to seek
SIGNS AND SYMPTOMS OF CHILD ABUSE AND NEGLECT
SIGNS AND SYMPTOMS OF CHILD ABUSE AND NEGLECT The warning signs and symptoms of child abuse and neglect vary from child to child. Children have different ways of coping with abuse and the signs often depend
How To Know If You Can Get Help From An Adult Counselor
1 Therapeutic Connections Counseling Services, PLLC Erika Meek, M.Ed., LPC, NCC 3550 Parkwood BLVD Suite A-201, Frisco, Texas 75034 Phone: (214)797-7961 Fax: (469)287-4107 Welcome to my office! I thank
PROBLEM ORIENTED SCREENING INSTRUMENT FOR TEENAGERS (POSIT) Developed by the National Institute on Drug Abuse National Institutes of Health
PROBLEM ORIENTED SCREENING INSTRUMENT FOR TEENAGERS (POSIT) Developed by the National Institute on Drug Abuse National Institutes of Health Problem Oriented Screening Instrument for Teenagers (POSIT) The
Adult Intake Information
Adult Intake Information Welcome to Eagle s Landing Christian Counseling Center! We know that you have many options for behavioral health care, and we appreciate your choosing our team to assist you. On
NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)
PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only) 1. What is the main problem that you are having? (If additional space is required, please use the back of this
Understanding. Depression. The Road to Feeling Better Helping Yourself. Your Treatment Options A Note for Family Members
TM Understanding Depression The Road to Feeling Better Helping Yourself Your Treatment Options A Note for Family Members Understanding Depression Depression is a biological illness. It affects more than
SAP Personal History/Psychosocial Evaluation Form Adult John Garlock, Ph.D., LPC, LCDC, CEAP, QSAP
1 SAP Personal History/Psychosocial Evaluation Form Adult John Garlock, Ph.D., LPC, LCDC, CEAP, QSAP Please complete all items on this form and return to Dr. Garlock. Thank You! Client s name: Gender:
Psychiatric Consultants of Atlanta, P.C. 1835 Savoy Drive Suite 101 Atlanta, Georgia 30341 Phone: 770-234-0981 Fax: 770-234-0252 www.pcatl.
Psychiatric Consultants of Atlanta, P.C. 1835 Savoy Drive Suite 101 Atlanta, Georgia 30341 Phone: 770-234-0981 Fax: 770-234-0252 www.pcatl.com CONTACT INFORMATION AND PERSONAL DATA Name: Date of Birth:
Psychological First Aid Red Cross Preparedness Academy 2014
Caring for Survivors of Trauma and Disaster: An Introduction to Psychological First Aid Biographical Information Rev. William F. Engfehr III LutheranChurch MissouriSynod DisasterResponseChaplain Senior
Date of Current Marriage/Separation: Highest Level of Education:
ADULT INTAKE FORM Name: Date: Social Security: Home Address: City, State, Zip: Home Phone: Work Phone: Cell Phone: May we call you and leave messages at home? Yes No May we call you and leave messages
It is important that you tell your family and the people closest to you of this increased sensitivity to opioids and the risk of overdose.
MEDICATION GUIDE VIVITROL (viv-i-trol) (naltrexone for extended-release injectable suspension) Read this Medication Guide before you start receiving VIVITROL injections and each time you receive an injection.
PATIENT INFORMATION FILL OUT ALL ITEMS
PATIENT INFORMATION FILL OUT ALL ITEMS FAILURE TO COMPLETELY FILL OUT THIS FORM MAY RESULT IN YOU BEING BILLED IN FULL Patient Last Name: First: MI:. Address:. Date of Birth: Gender: M or F Marital Status:
Psychological Assessment Intake Form
Cooper Counseling, LLC 251 Woodford St Portland, ME 04103 (207) 773-2828(p) (207) 761-8150(f) Psychological Assessment Intake Form This form has been designed to ask questions about your history and current
Michael Simpson, Ph.D. - Clinical Psychologist 954-217-3966 PATIENT INFORMATION
Michael Simpson, Ph.D. - Clinical Psychologist 954-217-3966 PATIENT INFORMATION PLEASE PRINT CLEARLY DATE NAME ADDRESS DX (OFFICE USE ONLY) CITY STATE ZIP OCCUPATION HOME PHONE EMAIL WORK PHONE CELLULAR
FAIRBANKS PHYSICAL THERAPY
REGISTRATION PAPERWORK CHECKLIST If you wish, you can save time and simplify the registration process by completing the registration paperwork before you arrive. This checklist will help make sure you
ANTISOCIAL PERSONALITY DISORDER
ANTISOCIAL PERSONALITY DISORDER Antisocial personality disorder is a type of chronic mental illness in which your ways of thinking, perceiving situations and relating to others are dysfunctional. When
Postpartum Depression and Post-Traumatic Stress Disorder
Postpartum Depression and Post-Traumatic Stress Disorder Emotional Recovery: Postpartum Depression and Post-Traumatic Stress Disorder By: Lisa Houchins Published: July 23, 2013 Emotions vary widely after
Helping Families Deal with Stress Related to Disasters
Helping Families Deal with Stress Related to Disasters Diana DelCampo, Ph.D., Child Development and Family Life Specialist ddelcamp@nmsu.edu A disaster is an event that: Involves the destruction of property,
EMU Psychology Clinic 611 W. Cross Street Ypsilanti, MI 48197 (734) 487-4987. Client Application Child
A. Identification 1. Child s name EMU Psychology Clinic 611 W. Cross Street Ypsilanti, MI 48197 (734) 487-4987 Client Application Child Birthdate Age Grade: Person(s) completing this form Today s date
Depression is a medical illness that causes a persistent feeling of sadness and loss of interest. Depression can cause physical symptoms, too.
The Family Library DEPRESSION What is depression? Depression is a medical illness that causes a persistent feeling of sadness and loss of interest. Depression can cause physical symptoms, too. Also called
Addiction Medical Clinic LLC
Chief Complaint and Symptom: Substance Abused: Current amount per use and Frequency/day used: Last use: Date & Time: Route: Current and in the past: Duration of Use: Both Current and Lifetime: Have you
Depression in children and adolescents
Patient information from the BMJ Group Depression in children and adolescents Depression is an illness that affects people of all ages, including children and teenagers. It can stop a child or teenager
Self Assessment: Substance Abuse
Self Assessment: Substance Abuse Please respond TRUE (T) or FALSE (F) to the following items as they apply to you. Part 1 I use or have used alcohol or drugs for recreational purposes. I use alcohol despite
Background Questionnaire for Diaconate Aspirants and Wives
Background Questionnaire for Diaconate Aspirants and Wives After you submit this form, click on "Home" and then my website link to return to my website to complete more forms. General Information Date
Child Welfare Trauma Referral Tool
Module 4, Activity 4F; Module 4, Activity 4G Child Welfare Trauma Referral Tool This measure is designed to help child welfare workers make more trauma-informed decisions about the need for referral to
Physical Symptoms Mood Symptoms Behavioral Symptoms
Prescription drugs are the 3 rd most commonly abused drugs amongst teens in Nebraska, and the same statistic holds true on a national level. The rise in prescription drug abuse is becoming increasingly
Wake Forest Mind and Health, PLLC 501 North Main Street Wake Forest, NC 27587
Wake Forest Mind and Health, PLLC 501 rth Main Street Wake Forest, NC 27587 Katherine E. Walker, PhD, LPC, NCC, BCIA-C Jennifer Endries, MEd, LPC Licensed Professional Counselor Licensed Professional Counselor
James H. Bramson, Psy.D., LCSW Licensed Clinical Psychologist (PSY-19459) Psychological & Organizational Solutions, Inc.
James H. Bramson, Psy.D., LCSW Licensed Clinical Psychologist (PSY-19459) Psychological & Organizational Solutions, Inc. 89 Moraga Way, Suite B Tel: 925-285-2429 Orinda, CA 94563 Fax: 925-429-9259 Name
The Global Relief Association for Crises & Emergencies G.R.A.C.E. COUNSELING INTAKE FORM
The Global Relief Association for Crises & Emergencies G.R.A.C.E. COUNSELING INTAKE FORM Personal Information Date: Name: Phone #: Cell #: May we leave a message on these numbers?: Best time to reach me
NLSY79 Young Adult Selected Variables by Survey Year
I. LABOR MARKET EXPERIENCE VARIABLES A. Current labor force and employment status Survey week labor force and employment status Hours worked in survey week Hours per week usually worked Job search activities
Cord of Three Counseling Services Addiction Recovery Intake Form
BACKGROUND INFORMATION Cord of Three Counseling Services Addiction Recovery Intake Form Client Home Phone Client Cell Phone Client Name: SSN: DOB: Address: City: State: GA Zip: Employer: Email: Occupation:
Associates for Life Enhancement, Inc. 505 New Road ~ PO Box 83 ~ Northfield, NJ 08225 Phone (609) 569-1144 ~ Fax (609) 569-1510 ~ 1-800-356-2909
Parents Names (If Client is a Minor) Client Information Sheet Client s Last Name First M.I.. Social Security No. Date of Birth: Age Sex M / F Home Phone No.( ) Education Level: Marital Status: Home Address:
Depression Overview. Symptoms
1 of 6 6/3/2014 10:15 AM Return to Web version Depression Overview What is depression? When doctors talk about depression, they mean the medical illness called major depression. Someone who has major depression
Child and Adolescent Developmental Questionnaire
Child and Adolescent Developmental Questionnaire Child s Name:. Age Date of Birth Person completing this form: Relationship: Sex: M / F Date: Current Problems What is the # 1 concern causing you to seek
University Counseling & Consulting Services Client Intake Forms
Date / / Name Last First Middle Name you prefer to be called Student ID Date of birth (mm/dd/yyyy) Home Phone OK to phone? Y N Cell Phone OK to phone? Y N Work Phone OK to phone? Y N E mail * *Provide
WHAT IS PTSD? A HANDOUT FROM THE NATIONAL CENTER FOR PTSD BY JESSICA HAMBLEN, PHD
WHAT IS PTSD? A HANDOUT FROM THE NATIONAL CENTER FOR PTSD BY JESSICA HAMBLEN, PHD Posttraumatic Stress Disorder (PTSD) is an anxiety disorder that can occur following the experience or witnessing of a
A story of bipolar disorder
A story of bipolar disorder (manic-depressive illness) Does this sound like you? D E P A R T M E N T O F H E A L T H A N D H U M A N S E R V I C E S P U B L I C H E A L T H S E R V I C E N A T I O N A
Trauma and the Family: Listening and learning from families impacted by psychological trauma. Focus Group Report
Trauma and the Family: Listening and learning from families impacted by psychological trauma Focus Group Report A summary of reflections and remarks made by Baltimore City families impacted by trauma and
For Parents and Families: What to do if a Child is Being Bullied
WHAT IS BULLYING? For Parents and Families: What to do if a Child is Being Bullied Bullying among children is aggressive behavior that is intentional and that involves an imbalance of power or strength.
Registered Charity No. 5365
THE MULTIPLE SCLEROSIS SOCIETY OF IRELAND Dartmouth House, Grand Parade, Dublin 6. Telephone: (01) 269 4599. Fax: (01) 269 3746 MS Helpline: 1850 233 233 E-mail: mscontact@ms-society.ie www.ms-society.ie
Alcohol and drug abuse
Alcohol and drug abuse This chapter explores how alcohol abuse affects our families, relationships, and communities, as well as the health risks associated with drug and alcohol abuse. 1. Alcohol abuse
Declaration of Practices and Procedures
LOGAN MCILWAIN, LCSW Baton Rouge Christian Counseling Center 763 North Boulevard, Baton Rouge, Louisiana 70802 Phone: (225) 387-2287 Fax: (225) 383-2722 Declaration of Practices and Procedures I am pleased
Memorial Hospital Sleep Center. Rock Springs, Wyoming 82901. Sleep lab Phone: 307-352- 8229 (Mon - Wed 5:00 pm 7:00 am)
Memorial Hospital Sleep Center Rock Springs, Wyoming 82901 Sleep lab Phone: 307-352- 8229 (Mon - Wed 5:00 pm 7:00 am) Office Phone: 307-352- 8390 (Mon Fri 8:00 am 4:00 pm ) Patient Name: Sex Age Date Occupation:
Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D
Be Fit Physical Therapy & Pilates, LTD Patient Registration Form Date: Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D Secondary Phone# (Home)(Cell)(Work):
PATIENT TREATMENT AGREEMENT
PATIENT TREATMENT AGREEMENT Patient Name: : As a participant in buprenorphine treatment for opioid misuse and dependence, I freely and voluntarily agree to accept this treatment agreement as follows: I
Essential Trauma Informed Practices in Schools. Shannon Cronn, N.C.S.P. Barb Iversen, M.C.
Essential Trauma Informed Practices in Schools Shannon Cronn, N.C.S.P. Barb Iversen, M.C. Objectives: Participants attending this session will be able to: Define trauma Explain how trauma may impact child/teen
Handout: Risk. Predisposing factors in children include: Genetic Influences
Handout: Risk The more risk factors to which a child is exposed the greater their vulnerability to mental health problems. Risk does not cause mental health problems but it is cumulative and does predispose
"Please answer the following questions about the past [two months] in your life?"
![Please answer the following questions about the past [two months] in your life?](/thumbs/20/408891.jpg "Please answer the following questions about the past [two months] in your life?")
PROBLEM ORIENTED SCREENING INSTRUMENT FOR TEENAGERS POSIT FOLLOW-UP QUESTIONNAIRE INSTRUCTIONS TO THE RESPONDENT "Please answer the following questions about the past [two months] in your life?" GUIDELINES
DENVER CHIROPRACTIC CENTER GLENN D. HYMAN, DC, CSCS
DENVER CHIROPRACTIC CENTER GLENN D. HYMAN, DC, CSCS Are you in the right place? Please read this before proceeding with paperwork: At Denver Chiropractic Center, we specialize in treating muscles with
Depression After Brain Injury A Guide for Patients and Their Caregivers
Depression After Brain Injury A Guide for Patients and Their Caregivers Is This Guide Right for Me? Yes, if: You have experienced a mild, moderate, or severe injury to your brain due to a sudden trauma.
Critical Incidents. Information for schools from Derbyshire Educational Psychology Service
Critical Incidents Information for schools from Derbyshire Educational Psychology Service Introduction to Critical Incidents A critical incident (CI) is any event that is unexpected, acute, stressful and
Amanda G. Johnson, LPC
Child Personal Information Child s Name: Date: Age: DOB: / / Gender: M F Race: Address: Apt: City: State: Zip Code: Father s Name: Date of Birth: / / Age Father s Occupation: Phone Number: Mother s Name:
Grapevine Behavioral Healthcare Associates 2311 Mustang Dr #300, Grapevine, TX 76051 Office (817) 481-7474 Fax (817) 416-0900
PATIENT INFORMATION Parent/Guardian Name (if patient is child/adolescent): Last Name: First Name: Middle: Social Security #: of Birth: Gender (please circle): Male Female Street Address: City, State, Zip
IS IT A MOOD OR A MOOD DISORDER
TEENAGE DEPRESSION & BIPOLAR IS IT A MOOD OR A MOOD DISORDER PRESENTED BY THE MOOD DISORDERS ASSOCIATION OF MANITOBA MOOD DISORDERS ASSOCIATION OF MANITOBA We are a self-help organization whose purpose
Please review, complete, and return all paperwork included in this packet. If you have any questions or concerns please feel free to contact us at
Your child has been referred to the Health4Life Program at Children's Healthcare of Atlanta. We are located at the Scottish Rite Campus in the Medical Office Building. In order to serve you and your child