The Interpersonal Healing Clinic, LLC

1006 Depot Hill Road, Suite D

Broomfield, CO  80020

O: 303-514-4058 F: 303-482-1331

drlisatempleton@yahoo.com

 

Client History and Background Form

Your honesty aids my work in terms of integrating themes and current life functioning.  Thank you for your time in filling out this form.

 

 

Patient's full name: _______________________________________    Date: _____________

 

Client's Social Security #___________________________    Age _______   Gender __F __M

 

Address_____________________________  City ________________State______Zip_______

 

Telephone___________________ work____________________ cell_____________________

 

Birthdate ___/____/_____  Race/Ethnicity_____________ 

 

Name of Spouse/Guardian________________________ Phone ________________________

 

Emergency Information

In case of emergency, please contact:

Name_____________________________ Relationship________________________________

Phone_____________________________ Address___________________________________

 

Employment Information

Client:   Place_______________________________ Occupation________________ Hrs_____

Spouse:Place_______________________________ Occupation________________Hrs______

 

Insurance Information

Primary Insurance________________________   Secondary Insurance __________________

Contract/ID#____________________________    Contract/ID#_________________________

Group/Acct#_____________________________  Group/Acct #_________________________

Subscriber______________________________   Subscriber __________________________

Subscriber DOB__________________________   Subscriber DOB______________________

Subscriber SS#__________________________   Subscriber SS#_______________________

Client's relationship to Subscriber?  ____Self  ____Spouse ____Son/Daughter

EAP?  ____yes____no

 

Referral Source

How did you hear about my services? _____________________________________________

Address_________________________ City___________________ State________ Zip______

Phone________________________________

Do you (client) have a:   ___conservator  ___guardian  ___representative payee

____No    ____Yes    Name__________________________  Phone_____________________

                                   Address___________________________________________________

Would you like to receive The IHC Newsletter with mental health tips for good health?___yes___no

 

Primary Reason for seeking services:

___Anger Management

___Anxiety

___Fears or Phobias

___Coping

___Mental Confusion

___Alcohol/Drugs

___Depression

___Sexual Concerns

___Eating Disorder

___Sleeping problems

___Other mental health or behavioral concerns

 

How long have you been experiencing these problems? ______________________________

 

Please check behaviors and/or symptoms that occur to you more often than you would like them to:

___Aggression                   ___Elevated Mood          ___Phobias/fears

___Alcohol dependence    ___Fatigue                      ___Recurring thoughts

___Anger                           ___Gambling                   ___Sexual Addiction

___Antisocial behavior       ___Hallucinations            ___Sexual Difficulties

___Anxiety                         ___Heart palpitations       ___Sick Often

___Avoiding people            ___High Blood Pressure  ___Sleeping problems

___Chest Pain                   ___Hopelessness            ___Speech problems

___Computer Addiction     ___Impulsivity                  ___Suicidal Thoughts

___Depression                  ___Irritability                     ___Thoughts disorganized

___Disorientation              ___Judgment errors         ___Trembling

___Distractibility               ___Loneliness                  ___Withdrawing

___Dizziness                     ___Memory Impairment   ___Worrying

___Drug Dependence       ___Mood Shifts                ___Other (specify_________)

___Eating Disorder            ___Panic Attacks        

 

What areas of your life are affected by the above?

 

Social

___Unable to form or maintain friendships

___Withdrawal from family and friends

___Increased conflict with others

___Loss of interest in social activities

___Phobias

 

Occupational

___Unable to maintain job

___Absenteeism

___Conflicts with co-workers

___Tardiness

___Reduced Productivity

___Disciplinary Action for Poor Performance

 

Academic

___failing grades

___truancy

___tardiness

___detention

___reduced productivity at school

___fighting/conflicts with students/teachers

 

Affective Distress

___crying spells

___mood swings

___anger/rage

___disorganized thoughts

___feeling overwhelmed with emotions

___worrying that interferes with the ability to concentrate

___memory problems

___concentration problems

 

Physical

___decreased energy/fatigue

___difficulty getting out of bed or insomnia

___decreased/increased appetite

___substantial weight loss or gain

___physical complaints (headaches, stomachaches)

___frequent illness

 

Family Information

Your current relationship status:

___single             ___divorce in process    ____unmarried, living together

___legally married   ___separated    ____divorced

___widowed         ___annulment

 

Assessment of relationship with significant other:  ___good   ___fair   ___poor   ___N/A

 

                                                                                         Living?       Living with you?

Relationship                      Name                     Age      Yes      No         Yes        No_______

Mother          ________________________ ______ _____ _____    _____     __________

Father          _____________________________________________________________

Spouse        _____________________________________________________________

Children      ______________________________________________________________

                   ______________________________________________________________

                   ______________________________________________________________

Others        ______________________________________________________________

 

Development

Are there special, unusual, or traumatic circumstances that affected your development? __yes ___no 

If yes, please describe ___________________________________________________

Has there been any history of child abuse _____yes   _____no

If yes, which type(s)?  ______sexual   ____physical   _____ verbal

Other issues   ____neglect   ___inadequate nutrition   ___poor health

___other (please specify)_______________________________________________________

 

Social Relationships

Check how you generally get along with other people (check all that apply):

___Affectionate   ___Aggressive   ___Avoidant   ___Fight/Argue Often   ___Follower

___Friendly         ___Leader          ___Outgoing  ___Shy/Withdrawn       ___Submissive

___Other (specify)____________________________________

 

Do you currently have supportive friendships?  ___yes   ___no

 

Sexual Orientation__________________________________________

Sexual Dysfunctions?   ___yes   ___no

 

Cultural/Ethnic

To which cultural or ethnic group, if any, do you belong?____________________________

Are you experiencing any problems due to cultural/ethnic issues? ___yes  ___no

If yes, please describe_______________________________________________________

 

Spiritual/Religious

How important to you are spiritual matters? ___not at all   ___little   ___moderate   ___much

Are you affiliated to a spiritual/religious group? ___yes ___no  

Which one?___________________________________________________________________

Would you like your spiritual/religious beliefs incorporated into the counseling?  ___yes ___no

 

Current and Past Legal Status

Are you involved in any active cases (civil or criminal)?  ___yes  ___no

If yes, please describe and indicate the court and hearing/trial dates and charges______________________________________________________________________

Are you presently on probation or parole?  ___yes   ___no

Please list any previous criminal or civil charges______________________________________________________________________

 

Education

Check all that apply

High School graduate?  ___yes  ___no

College graduate?        ___yes  ___no    Major______________________

Are you currently enrolled in school?   ____yes   ___no

Other Training?________________________________________________________________

 

Employment

Current Employer____________________________Dates______________ Title____________

_____FT___PT___TEMP___laid-off___disabled___retired___social security___student

Any military experience?  ___yes   ___no

If yes, which branch, type of discharge and rank at discharge____________________________

____________________________________________________________________________

 

Leisure/Recreational

Describe special areas of interest or hobbies (art, books, crafts, physical fitness, sports, outdoor activities, church activities, walking, exercising, diet/health, hunting, fishing, bowling, traveling, etc.)

Activities_____________________________________________________________

How often now?_______________________________________________________

How often in the past?__________________________________________________

 

Personal History of:

                                           Currently                   In the Past                       Never

Alcohol Abuse_________________________________________________________

Depression    __________________________________________________________

Drug Abuse   __________________________________________________________

Bipolar           __________________________________________________________

Suicide Attempt________________________________________________________

Nervousness  _________________________________________________________

Psychiatric Hospitalization _______________________________________________

 

Family History of:

                                           Currently                   In the Past                       Never

Alcohol Abuse_________________________________________________________

Depression/Anxiety    ____________________________________________________

Drug Abuse   __________________________________________________________

Bipolar           __________________________________________________________

Suicide Attempt________________________________________________________

Psychiatric Hospitalization _______________________________________________

Current and Past Health Concerns

Please list any current health concerns_________________________________________________________________

 

Past health concerns______________________________________________________________________

_______________________________________________________________________________________________________________________________________________________

 

Name of Primary Physician_________________________________ Phone_______________

Date of last physical exam______________________________________

Previous or upcoming surgeries?_________________________________________________

 

Do you have any disabilities?  ___no  ___yes   If yes, describe and note how it affects your physical

and/or psychological functioning and how you adjust to your disability______________

____________________________________________________________________________

____________________________________________________________________________

 

Current Medications

Name of current meds, dosage, when you take and how often as well as usage_____________

__________________________________________________________

Please list any nutritional and herbal supplements you currently take______________________

____________________________________________________________________________

How long have you been taking medication?_________________________________________

____________________________________________________________________________

Please list medications you have taken in the past____________________________________

How long did you take it? _______________________________________________________

Why was it stopped?___________________________________________________________

Medication Allergies? ___yes ___no  If yes, what allergies?_____________________________

____________________________________________________________________________

 

Nutrition

Meal                How often (per wk)          Typical foods eaten              Amount Eaten

Breakfast             ___/ week              ____________________   ___low ___med ___high

Lunch                  ___/ week              ____________________   ___low ___med ___high

Dinner                 ___/ week              ____________________   ___low ___med ___high

Snacks                ___/ week              ____________________   ___low ___med ___high

 

Chemical Abuse History

Please check which substances you have used in the past:

___alcohol   ___barbiturates   ___Valium/Librium   ___Cocaine/Crack   ___Heroin/Opiates

___marijuana  ___PCP/LSD  ___Inhalants   ___Caffeine   ___Nicotine  ___Over the counter

___prescription drugs  ___other

 

Are you using any of these substances currently? ___yes  ___no  If yes, which ones?______

_________________________________________________________________________

How often?___________ Use in the last 48 hours?______  In last 30 days?_____________

Explain___________________________________________________________________

Have you ever had any withdrawal symptoms when trying to stop using drugs or alcohol?

____yes   ____no  Please describe_____________________________________________

Have drugs ever created a problem for your job?  ____yes  ___no  If yes, please describe__

_________________________________________________________________________

 

Prior Counseling/Psychiatric Treatment

Have you had previous treatment?  ___yes   ___no    If yes, please describe your experience

__________________________________________________________________________

__________________________________________________________________________

Any previous mental health diagnoses? __________________________________________

What are your goals for therapy?________________________________________________

Do you feel suicidal at this time?   ____yes  ____no   If yes, explain____________________

__________________________________________________________________________

Are you currently involved in any risk-taking behaviors?______________________________

__________________________________________________________________________

 

 

 

 

Client's signature_________________________________________  Date_________________

 

Parent/Guardian (If applicable)______________________________  Date_________________

 

Therapist's signature/credentials________________________________________________

Date_____________