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Nichelle Chandler, PhD, RPT, LCDC, NCC, MAC, SAP
Licensed Professional Counselor
1106 Santa Fe Trail
Ste. 9
Duncanville, TX 75137
Office (469) 867-1343
E-mail:
PART 1: TO BE COMPLETED BY PATIENT
PATIENT NAME:______DOB:______
DATE COMPLETED:______
ADDRESS:______
PHONE:______
INSURANCE:_Id #______Auth # ______
Insurance name______
A. MAIN ISSUE(S):
Please describe the primary issues that prompted your request for treatment:
______
Issue Checklist:
Please indicate if you have had any of the following difficulties:
Behavior/ Issues Severity Number of months
(circle) the behavior has been present
Cutting or hurting yourself 1 2 3 4 5 6 7 8 9 10 ______
Mood swings 1 2 3 4 5 6 7 8 9 10 ______
Feelings of depression 1 2 3 4 5 6 7 8 9 10 ______
Weight change 1 2 3 4 5 6 7 8 9 10 ______
Over/under eating/ vomiting 1 2 3 4 5 6 7 8 9 10 ______
Disrupted/ disturbed sleep 1 2 3 4 5 6 7 8 9 10 ______
Poor energy level 1 2 3 4 5 6 7 8 9 10 ______
Social isolation/ withdrawal 1 2 3 4 5 6 7 8 9 10 ______
Difficulty thinking clearly 1 2 3 4 5 6 7 8 9 10 ______
Fears others wish you harm 1 2 3 4 5 6 7 8 9 10 ______
Hearing things others don’t 1 2 3 4 5 6 7 8 9 10 ______
Seeing things others don’t 1 2 3 4 5 6 7 8 9 10 ______
Anxiety or panic attacks 1 2 3 4 5 6 7 8 9 10 ______
Thoughts to hurt others 1 2 3 4 5 6 7 8 9 10 ______
Difficulty with concentration 1 2 3 4 5 6 7 8 9 10 ______
Easily agitated/ angered 1 2 3 4 5 6 7 8 9 10 ______
Excessive alcohol use 1 2 3 4 5 6 7 8 9 10 ______
Abuse of medications/ drugs 1 2 3 4 5 6 7 8 9 10 ______
Other addictive behaviors 1 2 3 4 5 6 7 8 9 10 ______
Phobias or obsessions 1 2 3 4 5 6 7 8 9 10 ______
Have you ever talked about or attempted suicide? Yes No If yes, please give details:
______
Have you experienced any traumas in your life (abuse, violence, family dysfunction, divorce, losses, other events)? Yes No If yes, please give details:
______
Do you have any history of abusive/ violent behavior toward others? Yes No
If yes, please give details:
______
B. PERSONAL HISTORY
What is your current relationship status? Married Single Divorced Widowed Separated Other significant relationship
Please give additional information about past and present significant relationships, including any difficulties (discord, unfaithfulness, sexual):
______
Have you had any history of involvement with the legal system? Yes No
If yes, please give details:
______
Please provide a history of any substance abuse:
Substance / Age of first use / Last use / Pattern (amount/ frequency)Alcohol
Marijuana
Hallucinogens
Amphetamines/ Stimulants
Opiates
Cocaine
Prescription drugs
OTC/ Other
Do you have any military history? Yes No If so, please give details:
______
Please indicate highest level of education achieved as well as any learning difficulties
______
Current occupation:______
Any history of work problems, including suspensions, firings, problems with co-workers or supervisors, etc:
______
How would you describe your religious and or cultural affiliations and the role they may play in therapy:
______
______
C. MEDICAL HISTORY
Please list any prescription (include dosages) or over the counter medications that are currently taking as well as the names of the prescribing physicians:
______
Do you have any significant medical issues, current or previous? Yes No If yes, please give details:
______
Please provide details of any current of previous mental health treatment, including providers, dates, results:
______
D. FAMILY HISTORY
Does anyone in your family have a history of psychiatric, emotional, nerve problems? Yes No If yes, please give details:
______
Drug and/ or alcohol problems? Yes No If yes, please give details:
______
Violence? Yes No If yes, please give details:
______
Who were you primarily raised by?
______
If not by biological parents, please indicate the reason(s):
______
How many brothers and sisters do you have?______
Do you maintain regular contact with them? Yes No
Why or why not?______
______
Were you part of a blended family? Yes No If yes, any comments about that:
______
Any other relevant family history:
______
E. OTHER
Please provide any additional information that may be helpful:
______
F. GOALS FOR THERAPY:
Please list some of the things that you hope to be accomplished in the process of therapy:
______
______
Patient Signature Date
THANKS FOR YOUR TIME IN COMPLETING THIS QUESTIONAIRE. PLEASE BRING THIS FORM, YOUR INSURANCE CARD IF APPLICABLE, AND ANY EAP APPROVAL/PRE-AUTHORIZATION FORMS WITH YOU FOR YOUR INITIAL APPOINTMENT.