Counseling for Faculty and Staff
Institute for Health and Human Services
Appalachian State University
Client Information Form
Date______
ClientName______Client Number______
Address______
Home Phone______May we leave message at this number?______
Work Phone______May we leave message at this number?______
Mobile Phone ______May we leave message at this number?______
Email ______May we contact you at this email?______
For couples:
Partner Name ______
Address______
Home Phone______May we leave message at this number?______
Work Phone______May we leave message at this number?______
Mobile Phone ______May we leave message at this number?______
Email ______May we contact you at this email?______
Occupation______Place of work ______
For Client:
Date of Birth______Age______
Male _____ Female _____
Faculty _____ Staff______Immediate Family Member (relationship to employee)______
Academic Affairs______Business Affairs______Student Development______
University Advancement______Chancellor’s Office______
Occupation______Place of work______Years working at ASU____
Referral Source: Self ______Supervisor______Co-worker ______
Relative ______Friend______Other (Specify)______
Race/Ethnic Background (optional)______
Emergency Contact: Name______
Phone(s)______
Marital Status: Single___Married___Significant Other____ Widowed___Separated___Divorced (# of times___)
Resides with______Relationship______
ChildName Age Child Name Age Child Name Age
______
______
What are the issues you would like to discuss with a counselor? ______
______
______
Medical Conditions (Surgeries, serious accidents, injuries, illness, seizures, disability, other)
Current______
Past______
Developmental Condition or Impairment______
______
Medicines Purpose? Dosage When did you start the medicine?
______
______
______
Physician/Psychiatrist Name______Phone______
How many days did you drink alcohol in the past week? Circle one
0 1 2 3 4 5 6 7
What would you say is your average amount of consumption per week? (a drink equals 1 beer,
1 glass of wine, 1 ounce of alcohol per mixed drink)
______0 drinks ______1-2 drinks _____3-4 drinks
______5-6 drinks ______7-10 drinks ______11+ drinks
Do you use any drugs or medications in ways that are not currently prescribed for you? Yes___ No___
If Yes, which drugs or medications do you use and how often?______
______
______
Do you find that you have tried to cut down on alcohol or drug use unsuccessfully? Yes___ No___
Do you find that it takes more alcohol or drugs to achieve the same effect? Yes__ No__
Has drug or alcohol use hurt your work performance, relationships, caused a blackout, legal problems,
guilt, depression, decreased motivation, personality change, or other problem______?
_____Substance use/abuse/dependence by spouse/significant other/extended family member
Client Name______Client Number______
Family History (family of origin data: parents, siblings, losses, quality and emotional closeness or
distance of family life, problems/strengths; current family data: problems/strengths)
______
______
Previous therapy
____Outpatient (Where, when, length of treatment)______
______
____Inpatient (Where, when, length of treatment, voluntary/involuntary commitment)
______
Psychiatric history infamily/extended family______
______
______
History of Violence
____No significant history
____Victim/witness of physical/sexual/emotional abuse/assault/trauma______
______
______
______
____Verbal/physical acting out toward others______
______
____Violence toward self______
______
Legal Issues______
Please check any concerns you have had in the last six months:
Abuse/Assault Substances:Alcohol/Drugs
_____Emotional _____Abuse/Dependence
_____Physical _____Codependency
_____Sexual _____Adult Children of Alcoholics
_____Adjustment _____Posttraumatic Stress Disorder
_____Aging/Retirement _____Psychosis
_____Anger Management _____Racial/Cultural
_____Anxiety/Stress
_____Career/Work Performance Relationships:
_____Depression _____Friend/Co-worker
_____Developmental _____Parents/Family
_____Eating Disorder/Weight _____Partner/Children
_____Financial _____Subordinate
_____Gambling _____Supervisor
_____Grief/Loss
_____Hallucinations _____Self-esteem
_____Health/Illness _____Sexual
_____Impulse Control _____Spiritual/Religious
_____Legal Problems _____Suicidal Behavior
_____Neurological Problems _____Suicidal Thoughts
_____Obsessions/Compulsions _____Other (Please specify)______
_____Personality Disorder
_____Phobia
Thank you for taking the time to fill out these forms.
Client Name______Client Number______
To be completed with counselor:
Mental Status (Circle all that apply)
Appearance: WNL; neat/clean; clothes/hygiene poor; eccentric; seductive; age-appropriate
Motor Activity: WNL; unusual gait; tics; hyper- or hypo-posturing; tremor; agitation; slowed
Eye Contact: WNL; good; evasive; poor
Attitude: cooperative; minimally compliant; hostile; actively resistant; disrespectful; uninvolved; arrogant; confused; solicitous
Oriented: time; place; person; circumstance
Memory: WNL; problems with concentration/recent memory/remote memory; confabulation; amnesia
Speech: WNL; loud; soft; slowed; mute; slurred; stuttering; excessive; reduced; pressured; offensive
Flow of Thought: WNL; blocking; tangential; flight of ideas; perseverative; indecisive
Content of Thought: WNL; obsessions; compulsions; phobias; antisocial attitudes; feeling persecuted; ideas of hopelessness/helplessness/worthlessness/guilt; blames others; feelings of unreality; sexual preoccupation; excessive religiosity; ideas/delusions of grandeur/persecution/reference; paranoia; somatic preoccupation
Sensory Functioning: WNL; hallucinations; illusions
Physical Functioning: WNL; sleep problems______; eating issues______(Describe under Comments below.)
Intellect: WNL; impoverished knowledge/vocabulary; poor abstraction
Insight: WNL; impairment: mild, moderate, severe
Judgment: WNL; impairment: mild, moderate, severe
Mood/Affect: WNL; inappropriate; flat; sad; depressed; irritable; anxious/panic/agoraphobia/social withdrawal; angry; manic/hypomanic; labile
Dangerousness: Yes___No___If Yes: Suicidal thoughts/plans/intent
Homicidal thoughts/plans/intent
Previous attempts______
Comments:(Details re any of the above, eg symptoms of depression, types of depression, seasonal etc)
______
Client Strengths:______
______Support System:______
______
Intake Counselor Signature Date
Treatment Plan Date______
(Include: Goal(s) stated in behavioral terms in measurable amounts;
Recommended Service/Intervention (Individual, marital, family, group therapy; workshop; referral; substance abuse assessment, treatment, referral)
Estimated length of service)
______
______
______
______
______
______
______
Counselor Signature
Treatment Plan Update Date______
______
______
Counselor Signature
Discharge Summary Date______Number of sessions______
Type of Service Closing Status
_____Intake Only _____Termination (Complete)
_____Individual, Couples, Family, Group Therapy _____Client did not return
_____Assessment _____Referral
_____Consultation
_____Emergency
Summary of Treatment (include whether goals met or to what extent) ______
______
Counselor Signature
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