Adaris Pickett, LICSW, Ed.S., RPT-S
P.O. Box 262 Templeton, MA 01468
978-894-0530office 978-894-0532fax
Introductory Questionnaire
PLEASE PRINT FORM, FILL OUT, AND BRING TO FIRST APPOINTMENT
This questionnaire is designedtobuild a foundation fortherapy. By responding tothese questions as thoroughlyas you can,
you will be:
•Gatheringbasicinformationmoreefficientlyandeffectively
•Helpingmegettoknowyouinamorefocusedway
•Providingahistoricalbackgroundforpresentconcerns
•Directingattentiontokeyareas
•Clarifying currentconcerns
•Preparingtodevelopatherapeuticplan
Yourresponsesarestrictlyconfidential, and protectedby law to the extent of thelaw. No portion of thisdocumentwillbereleasedtoothers without yourpermission, except ifrequired by law.
If you have any questions,pleasefeelfreetoask.Somequestions may not pertain toyou. If there is a questionyoudonotwishtoanswerinwriting, just let me know.
General Information
NameDOBAge
AddressCityZip
PhonePhone (alternate)
EmailPreferred method ofcontact?
How were you referred?
Your Occupation
Your Employer
Current Marital Status
Spouse's NameDOBAge
Spouse's Occupation
Spouse's Employer
Emergency ContactPhone
Do you have children? YNStepchildren?YN Grandchildren? Y N
Children's Names / Gender / AgeGender / Age
Gender / Age
Gender / Age
Gender / Age
Stepchildren'sNames / Gender / Age
Gender / Age
Gender / Age
Grandchildren'sNames / Gender / Age
Gender / Age
Gender / Age
Description of present problems
Please state in your own words the natureof your main concern(s):
Please indicate how distressing yourconcern is right now:
Mildly upsettingModerately upsettingVeryupsettingExtremely upsettingTotallyupsetting
Whendidthisconcernbegin?Givedatesifpossible:
Please describe any important events atthattimeor since then which may havestarted the concern or that keep itgoing:
Inwhatwayshaveyoutriedtoresolvethisconcern?
In what ways was thathelpful?
What obstacles remain?
Have you been in therapy before orreceived any prior professional orsupport group assistance for yourconcern? If so, what was helpful at that time?
Family of originhistory
Number of brothersAgesMarried?Children?
Number of sistersAgesMarried?Children?
Other significant family of origin members
Father's history
Living? YNAgeHealthBirth Father?
Occupation
If deceased:
What was his age and cause of death?
What was your age at the time of hisdeath?
Indicate any mental or physicaldifficulties your father has or has had:
Depression / Anxiety / MentalIllness / PhysicalIllnessRelationshipProblems / DrinkingProblems / DrugProblems / SuicidalThoughts/Attempts
SpiritualProblems / FinancialProblems / GamblingProblems / ProblematicInternet Use
Anger Management Problems
Other
Mother's history
Living? YNAgeHealthBirth Mother?
Occupation
If deceased:
What was her age and cause of death?
What was your age at the time of herdeath?
Indicate any mental or physicaldifficulties your mother has or has had:
Depression / Anxiety / MentalIllness / PhysicalIllnessRelationshipProblems / DrinkingProblems / DrugProblems / SuicidalThoughts/Attempts
SpiritualProblems / FinancialProblems / GamblingProblems / ProblematicInternet Use
Anger Management Problems
Other
Parents’ history
Areyourparentscurrently married?If no, has either of your parentsremarried?
Was either parent previouslymarried?
Spiritual history
Your religious affiliation as a childAsan adult
CurrentchurchaffiliationPastor's name
Howwouldyourdescribeyourcurrentspiritual/religious life?
In what ways is this a personal strength for you?
Would you like to explore spiritual matters in more detail? ☐YES☐NO ☐NOTSURE
Nationality
Does your family affiliate with anationality or country of origin?
If yes, please describe:
In what ways is this a personal strength for you?
Childhood andAdolescence
Circle any of the following that appliedduring your childhood or adolescence:
happy childhoodunhappy childhoodemotional problemseating disorder
family problemsphysical abusealcohol abusesexual abuselegalproblems drug abuse school problems medical problems financial problems abortion
other
Ifyouwerenotraisedbyyourparents, whohelped raise you?
Between what ages/years?
Pleasedescribeyourfather's (orfathersubstitute's)personality and his methodsof discipline (past present):
How did he show affection and how often didhe share his affection with you?
Inwhatwaysdidheinfluenceyouorothersmembers of the family?
Pleasedescribeyourmother’s (ormothersubstitutes) personality and her methodsof discipline (past present):
How did she show affection and how often did she share her affection with you?
In what ways did she influence you orothers members of the family?
What were the prevailing emotionalovertones in your family while you weregrowing up?
Hasanyclose relation hadsignificantproblems?If yes, pleasedescribe:
Hasanycloserelationexpressedsuicidalthoughts?Behaviors?If yes,please describe:
Has any relative had serious problems withthe law?If yes, pleasedescribe:
Physical
What is your height?Weight?
Doyouhaveorhaveyoueverhadanyofthefollowing? (Please describe):
Illnesses or physicalconditions
Surgeries
Unusual physicalcharacteristics
Unusual sensations
Troubling physical symptoms
Other
Current medications:
Prescribed by:
Allergies:
Name and phone number of your familyphysician:
Most recent full physical examination:
Results:
How would you describe your overall health?
Educational
Please list the last completedgrade/degree(s) in school:
Specialized areas of study:
Current educational activities:
Occupational
What sort of work are you currently doing?
Doesyourpresentworksatisfyyou?Please describe:
What were your past ambitions ordreams?
What are your current ambitions or dreams?
What kinds of hobbies or leisure do youenjoy or find relaxing?
Financial
What is your household income?
How much does it cost you to live?
Do your concerns include financial issues?If so, please describe:
Behavioral
Please circle and describe any of thefollowing behaviors that apply to you:
overeatingaggressivebehavior / odd behavior
problematicsexualbehavior / phobicavoidance
passivebehavior
lying pattern / worrying / vomiting
nervous tic / insomnia / outburstsof temper
lossofcontrol / procrastination / smoking
laziness / drinkingtoomuch / working too much
use of drugs
taketoomanyrisks / can'tkeepajob impulsivereactions / compulsions
fooduseproblems
crying / withdrawal / sleepdisturbance
Concentrationdifficulties / gambling / problematic internetuse
other
Have you been hospitalized forpsychological or emotional problems?
If so, when andwhere?
Menstrual history
AgeoffirstperiodWere you knowledgeable or was it asurprise?
Are your periods regular?Doyou experience pain?
How does your cycle affect your mood?
Sexual
Please describe your parents' attitudetoward sex:
Was sex discussed in your home?
When and how did you derive your firstsexual knowledge?
When did you first be come aware of yourown sexual impulses?
Have you experienced anxiety or guiltfeelings arising out of sex ormasturbation?
If yes, please describe:
Are your first or subsequent sexualexperiences relevant?In what way?
Isyourpresentsexlifesatisfactory?Please describe:
Haveyouexperiencedsignificanthomosexualthoughts or relationships?
Pleasedescribeanysexualconcernsnotdiscussed above:
Your current family
Whom do you include in the group youconsider your current "family"?
How would you describe your currentfamily?
What are the prevailing emotional overtonesin your current family?
Marriage
How long did you know your spouse beforeyour engagement?
How long were you engaged?
Howlonghaveyoubeenmarried?Previously married?
Ifpreviouslymarried,for how long?How soon were you remarried?
Was your spouse previously married?Ifso, for how long?
How soon was he/sheremarried?
How would you describe your relationshipwith your spouse?
Children
Please,describeyourmethodsofdiscipline(past and present):
Please,describeyour spouse's and/orparentingpartner'smethods of discipline(past and present):
Doanyofyourchildrenpresent specialproblems?Please describe:
Family Life
How do you show affection and how often doyou share affection with your family (pastand present)?
In what ways do you influence other membersof your family?
How does your spouse show affection andhow often do they share affection withothers in your family (past and present) ?
In what ways does your spouse influence youand other members of your family?
Friendships
Do you make friends easily?
In what ways are your friendships importantto you?
To whomwouldyou be most likely to turn forhelp?
Please,ratethedegree to which yougenerallyfeelcomfortableandrelaxed in social situations:VeryrelaxedRelativelycomfortable Relativelyuncomfortable Veryanxious
Stress
Check and describe any of the followingthat apply and indicate the person involved such as a spouse, child,father, mother, brother, sister,yourself,etc.Pleaseindicatethoseyouconsider important.
Deathinthefamily
MiscarriageDivorce Trouble with the lawFinancial
trouble
Job/Schoolproblems Geographic relocation
Seriousillness
Seriousoperation
Abortion
Mentalillness
Alcoholproblems
Drugproblems
Interpersonalproblems
Physicalabuse
Sexualabuse
DepressionSuicidal thoughts
Suicidalattempts
Spiritualproblems
Anger management problems
Unresolvedconflict
Other
Systems outside of your immediate family
How do you relate with your in-laws?
Have your parents, relatives, or friendssought to influence your situation?
Please describe:
Isyourjoborschoolsituationunusuallystressful?
Please describe:
Has your pastor, priest, or other clergymade a special effort to talk with youabout your
situation?Doyou consider him/her available to you in this life situation?
Please describe:
Havethepoliceorothersocialagenciesinfluenced your family?
Please describe:
Have there been any other significantoutside influences on your family?
Please describe:
Expectations regardingtherapy
In a few words, what do you think therapy is allabout?
How long do you think therapy should last?
How do you think a therapist shouldinteract withclients?
What personal qualities do you think theideal therapist should possess?
How would you describe a desired outcome for therapy?
Please use this area to describe any other related matters you may have that have not been addressed by thisquestionnaire.
Please be sure to read the attached consent form. We will sign it together when we meet.
CONSENT FOR TREATMENTAGREEMENT
Client name (pleaseprint):
I, the undersigned, hereby attest that Iam voluntarily seeking therapy with AdarisPickett.Iunderstandthat eitherpartymaydiscontinuethetherapeuticrelationship at any time.
NON-VOLUNTARY DISCHARGE FROM TREATMENT
Treatment may be terminatednon-voluntarilyiftheclientexhibitsphysical violence or verbal abuse,carries weapons, or engages in illegalacts. Treatment may also be discontinuedif the client does not participateactively in the therapy process. Theclient will be notified of the non-voluntarydischargeverballyand/orbyletter. Referral options may be discussedat the client’s request.
OFFICE POLICY
I, the undersigned, may cancel orrescheduleanappointmentbycalling978-894-0530 (24 hours a day). I willgive 24 hours notice of the need tocancel or reschedulemy appointment. Inlieuof24 hours notice, I will beresponsible for a $50 late cancellationfee.
I, the undersigned, agree andacknowledge that I am responsible forfull payment of services rendered.Payment for sessions will be made at thetimeofserviceunlessother arrangements have been made.
Insurance reimbursement, if available, willbe discussed at my request.
CONFIDENTIALITY
Confidential client records are maintainedby the therapist, and are protected by law. Session contents are held inconfidence and will not be released without the client’s permission except whererequiredbylaw,orinamedical emergency.
Informationconcerningchildabuseorneglect,frailelderabuse,orthreatofhomicide or suicide is not protected bylaw,andmustbereportedtoappropriateauthorities. Further, it is thetherapist’s duty to warn any potentialvictim when threat of harm has been made.
My signature below indicates that I havereadandunderstandtheprovisionsofthisdocument.
Signature of client/legalguardian(s):
Date
Date
Witness:
Date