Turning Point Mental Health Services, LLC

Please answer these questions as completely as possible.

Thank you for choosing Turning Point!

How did you hear about us?

______

IDENTIFYING INFORMATION

Name: ______Date of Birth: ______Age: ______

Address:______Phone: ______

County: ______City: ______State: ______

Zip:______

Email Address:------

Insurance Type: ______ID # ______Group # ______

Occupation: ______Education / highest grade level completed:______

Gender: M FEthnicity/race: ______

Relationship Status: M D S W OIf married/partnered, how long? ______

Do you have a legal guardian or are you under commitment? Y N

Do you live alone? Y N

If No, who resides with you in the home:

Name ______Age______Relationship______

Name ______Age______Relationship______

Name ______Age______Relationship______

Is there a family member or other significant person you may want to include in your treatment at Turning Point?

______

MAIN PROBLEM:

What is/are the main problem(s) for which you are seeking help? Please try to be specific about how this affects your life. How long has this been a problem?

SYMPTOM/PROBLEM LIST:

Please check symptoms that have been a concern or problem within the last 2 months:

PHYSICALADDITIONAL COMMENTS

Sleep problems____

Lost interest____If yes, in what activities: ______

Weakness, fatigue____

Appetite changes____

Weight changes____

Changed level of activity____

Bed wetting ____

MOOD

Morbid thoughts____

Suicide plans____

Depression____

Upward mood swings____

Self-harming behavior____

(cutting, burning, banging, hair-pulling)

FEELINGS

Guilt____

Excessive worry, fearfulness____

Anxiety or panic attacks____

Social fears, shyness____

Perfectionism____

Impulsive decisions____

BEHAVIOR

Avoidance (phobia)____

Withdrawn____

Unassertiveness____

Hyperactivity____

Aggressive behavior____

Irritability____

Lying____

Stealing ____

Running away____

Impulsive actions____

Binging on food____

Voluntarily vomiting ____

Inability to break habit____

Alcohol or drug use/abuse____

THOUGHTS/PERCEPTIONS

Concentration problems____

Fantasy____

Preoccupation____

Thoughts about suicide____

Suicide threats____

Personality Change____

Thoughts being controlled____

Hallucinations (voices, visions) ____

Memory loss____

Disorientation/confusion____

Time frame of Previous Services/ help sought:What other help have you sought?

PLEASE LIST SPECIFIC DATES/ Include Provider Name(or approximate month/year and # of days).

Mental Health Services / Dates of Service / Mental Health Services / Dates of Service
FROM / TO / FROM / TO
Individual Psychotherapy / Family Psychotherapy
Partial Hospitalization / Inpatient Hospitalization
ACT / Day Treatment
Group Psychotherapy / IRTS
Emergency Services / ARMHS
Medication Management / Other DBT (describe)
Crisis Response Team / Other (describe: e.g, CD, eating disorders, etc.)

MEDICAL HISTORY: Please check and describe any area that is or has been a significant medical problem:

AREAPRESENTPASTPLEASE DESCRIBE

Allergies______

Head, ear, nose, throat______

Visual, hearing______

Lungs, breathing______

Heart, circulation______

Infectious disease ______

Digestive, liver______

Reproductive, sexual______

Muscles, bones, joints______

Epilepsy, neurologic______

Thyroid, diabetes______

Primary physician / clinic name: ______

Turning Point recommends yearly physical examinations. When was your last physical examination? ______

MEDICATIONS

Please list current medications. If known, give dose.

FAMILY ILLNESS TREATMENT

Please list any diagnosed or suspected mental illness (i.e.: depression, hyperactivity, anxiety, alcohol/drug problems) and / or history of medical illness (i.e.: diabetes, heart disease, etc.) in family members.

DEVELOPMENTAL MILESTONES

Did you walk, talk, and potty train at an appropriate age time?

Please briefly describe any problems/concerns:

Did you receive any special education services?

Have you ever been abused in your life?

If yes: physically?____ sexually?____ emotionally?____

When did this occur?

Do you have a psychiatrist?

If yes:Name:______Location:______

Do you have a social worker?

If yes:Name:______Location: ______

Do you have a probation or parole officer?

If yes:Name:______Location:______

SUBSTANCE ABUSE

Do you use alcohol and/or other drugs? ______If so, what areyour reason(s): ______

______

What chemical(s) do you use? (Please list all) ______

If you use tobacco products, please indicate type and how much: ______

When is the last time you usedalcohol and/or other drugs? ______

Have you ever felt like you needed to cut back on your alcohol or drug use?YES NO

Have people annoyed you by criticizing your drinking or drug use?YES NO

Have you ever felt bad or guilty about your drinking or drug use?YES NO

Have you ever had an “eye-opener” (drink/used drugs first thing in the morning)?YES NO

Do you ever have blackoutswhen you drink or use drugs?YES NO

(don’t remember part of the evening/day)

Do you ever have the shakes in the morning?YES NO

Do you ever go days at a time with heavy drinking/using?YES NO

Have you ever lost a job because of drinking/using? YES NO

Please complete all enclosed Release of Information Forms for the following:

  1. Psychiatrist
  2. Primary Care Doctor
  3. Case Manager
  4. ARMHS Worker
  5. Other Therapists you have seen in the past 7 years.

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