The Interpersonal Healing Clinic, LLC
1006 Depot Hill Road, Suite D
Broomfield, CO 80020
O: 303-514-4058 F: 303-482-1331
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_____________