Cascadas Counseling

2350 Central Blvd, Brownsville, Texas 78520

Phone(956) 621-2043

Fax (956) 621-4093

ONLINE BIOPSYCHOSOCIAL HISTORY

Identifying Information

Client Name: ______

Date of Birth/Age: ______

City, State of Birth/Residence: ______

Gender:_____ Female_____ Male

Race/Cultural Background: ______

Presenting Problem

What are the situations or circumstancesyou need help with? ______

______

______

______

How has it affected your family? ______

What are you doing different about your situation?______

Your Physical Health

What does your day mostly look like (e.g. mood, work, family, routine, etc.)? ______

______

______

Are you: Passive Passive-Aggressive Aggressive Assertive

How is your physical health? Poor Fair Good Excellent Superior

Do you get headaches or migraines? Yes No

Do you exercise, work out or play any sports? Yes No

Digestive problems (nausea, pain, heartburn, constipation, indigestion, diarrhea)? Yes No

Unexplainable chronic pain throughout your body? Yes No

Current medical concerns or health problems/allergies:______

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Your Mental Health

Describe any psychological problems you may have had in the past. ______

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Have you ever been hospitalized for any mental health issues? _____ Yes _____ No If yes, please discuss more.

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History of inpatient or outpatient therapy: ______

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Current medications:

Medication / Prescribing Doctor / Reason Prescribed As Client Understands / Dose / Duration of use

Family History

Were you adopted? Yes No If yes, do you have concerns about your adoption? ______

Mother: name, age, work, and your relationship with her out of 10. Describe her in three words.______

Father: name, age, work, and your relationship with him out of 10. Describe him in three words: ______

______

Are your parents: Married _____ Remarried ____ Never Married _____ Separated _____ Divorced _____ Deceased _____ Common Law _____

If parent(s) are deceased, who/when/how did he/she die? ______

______How old were you? _____ How aware were you of the death; how were you told? ______

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How do(did) your parents, whether living in the home or not, get along with each other? ______

Who lives with you at home? ______

How do the people in your house get along with each other? ______

If applicable, what is your stepfather's name and kind of relationship you have? ______

If applicable, what is your stepmother's name and kind of relationship you have? ______

What are your siblings’ names, ages, and what is your relationship with them like of 10? ______

Is there anybody with mental health issues in your family? Please describe. ______

______

Has anyone in your family ever committed suicide? Yes No

If yes, please describe.

Has anyone in your family had problems with drugs, alcohol, sex, gambling, etc.? Yes No

If yes, please describe.

Life Changing Events

Did you experience any life changing events/traumas as a child (deaths, abuse, bullying, accidents, domestic violence, separation/divorce, etc)?______

Do you have any legal issues, such as open CPS cases or history of, custody arrangements, etc. you are aware of? Please explain: ______

Social Support

Are you: Married Remarried Single Separated Divorced Widowed Common Law a BF/GF

What is their name and for how long? ______

Do you have children? If so, what are their names, ages, and relationship like? ______

______

Describe your religious beliefs and habits. ______

Describe your groups of friend. (Is it easy or hard to make friends? Are they trustworthy and keep you from trouble)

Hobbies and Interests? ______

School History

What is the highest level of education you have completed or are currently in? ______

What grades do you usually get? Are your grades satisfactory to your standards? ______

Did you have any problems in school most students didn’t? ______

______

Substance Misuse and Co-Dependency History

What substances have you tried?

Substance / Frequency/Quantity Consumed / Onset Age / Last Usage / Period of Abstain Yrs./Mos. / Negative Consequences / Sell? Y/N / Misuse/Abuse (A), Dependant (D),
Experimental (E)
Alcohol
Marijuana
Methamphetamines
Cocaine
MDMA (E)
Crack
Inhalants
LSD
Mushrooms
Roofies, R2s
Prescribed Meds
(Xanax, Prozac)

Y N Have you increased the amount of substance to achieve the same high?

Y NHave you experienced withdrawal symptoms? (e.g.: cravings, sweating, tremors, hallucinations)

Y N Have you had a persistent desire or unsuccessful efforts to cut down or control you use?

Y NDid you spend a lot of time trying to obtain more, using it or recovering from its effects?

Y NDo you smoke cigarettes?

Do either of your parents or other family members drink or use drugs? Y N Have you ever drank /used with them? ______

Where have you most often used these substances? ______

What’s the worst thing that’s happened to you because of drinking/drugs (blackout, hangovers, etc.)? ______

______

Sexual History

Were you ever the victim of molestation, abuse, rape, or sexual assault? Please describe. ______

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What was your primary source of sexual education growing up? ______

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Strengths and Areas of Improvements

In your own words, what are your strengths – what are you really good at? ______

In your own words, what would you like to be better at or to improve? In other words, how can I help you? ______

THANK YOU FOR YOUR HONESTY IN COMPLETING THE ONLINE VERSION OF OUR BIOPSYCHOSOCIAL HISTORY IN ORDER TO SERVE YOU BETTER!

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Client Signature and Date

Cascadas Counseling - 2015