Your Family Clinicsocial History

Your Family ClinicSocial History

514 Old Richton Rd. Adult Form

Petal, MS 39465 601-408-7203 601-544-8935

Instructions: It is very important that you answer all the items as completely and as detailed as possible. If you do not know the answer to a question just put a question mark (?). If the question does not apply, just put NA for not appropriate. Your help on this is much appreciated.

Your name: ______Birth-date:______Age: ______

Parent’s names:______

Spouse or Partner’s name: ______

Your home phone: ______work phone ______cell phone ______

Your current place of employment and number of hours of work per week ______

Your spouse’s (or partner’s) place of employment and # hours work per week ______

Son’s names and ages ______

Daughter’s names and ages______

In 3 or 4 sentences please describe your concerns that brought you to Your Family Clinic:

What promoted you to seek help at this time?

Have your ever received previous psychiatric, psychological, counseling services or been hospitalized for emotional/behavioral problems? ______If yes, how many times? ______

When ______Where ______Name of Therapist ______

If you have one, what is your current psychiatric diagnoses (e.g., depression, anxiety)? ______

______

What psychiatric diagnoses (e.g., depression, anxiety) have you had in the past? ______

______

Who gave you the referral to Your Family Clinic? ______Is it OK if we contact them? __

Name of Current Physician ______When was the last visit? ______

Medications your are currently taking (Please include dosage and frequency) ______

______

Medications your have taken in the past ______

______

______.

Please circle any of the following that apply to you now and indicate for how long it has been a problem (Please note: yrs= years; mo = months):

poor attention span ____ yrs ____mostealing ____ yrs ____mo

hyperactivity ____ yrs ____modrug/alcohol use ____ yrs ____mo

easily distracted ____ yrs ____mocigarettes ____ yrs ____mo

restless ____ yrs ____mosadness ____ yrs ____mo

difficulty going to sleep ____ yrs ____mofears ____ yrs ____mo

difficulty staying asleep ____ yrs ____moanxiety ____ yrs ____mo

difficulty awakening ____ yrs ____mocrying ____ yrs ____mo

bed wetting ____ yrs ____moworries ____ yrs ____mo

suicidal ideation ____ yrs ____moirritable ____ yrs ____mo

homicidal ideation ____ yrs ____modefiant ____ yrs ____mo

temper tantrums ____ yrs ____moanorexia or bulimia ____ yrs ____mo

use of laxatives to lose weight ____ yrs ____mo seeing things that are not there ____ yrs ____mo

aggressive ____ yrs ____mohearing things that are not there ____ yrs ____mo

fighting ____ yrs ____monightmares ____ yrs ____mo

poor social skills ____ yrs ____morepetitive behaviors ____ yrs ____mo

(please specify:______)

destructive ____ yrs ____mocompulsive behaviors ____ yrs ____mo

(please specify:______)

sexual problems ____ yrs ____mo too much stress ____ yrs ____mo

too much work ____ yrs ____mo sexual abuse as a child ____ yrs ____mo

sexual abuse as an adult ____ yrs ____mo physical abuse as a child ____ yrs ____mo

physically abused as an adult ____ yrs ____mogambling problems ____ yrs ____mo

financial problems ____ yrs ____mo cutting on self or self harm ____ yrs ____mo

obsessions ____ yrs ____mo feeling empty ____ yrs ____mo

(please specify: ______)

Birth Information

Pregnancy and Birth: If adopted, indicate at what age ____ If adopted, were your natural parents a relative? ____

Parent’s ages when you were born: Mom______Dad______Were your parent’s ever divorced? ____ If yes, how old were you when they separated? ______Who was your primary caretaker? ______

Did either parent use alcohol or drugs before the pregnancy? _____ if yes, whom? ______

Did either parent use alcohol or drugs during the pregnancy? _____ if yes, whom? ______

Was your mother ever hit during pregnancy? ____ if yes, by whom? ______

Where there any problems or concerns about your birth? ______If yes, please explain: ______

______

______.

Were there any developmental problems during your infancy or childhood years? ______If yes, please describe:

Medical Information

Please list your current medical problems:

Please list your medical problems of the past:

Who are your current medical doctors (please include their phone numbers):______

______

Trauma

Please describe any incidents of sexual, physical or emotional abuse in your life.

Have you ever been sexually inappropriate? ____ if yes, please describe:

Please describe any accidents that you have been involved in:

Has there ever been any domestic violence or spouse abuse in your life? ____ if yes, please describe:

Has your ever lost a significant family members or friends? _____ if yes, please describe:

Relationships

Please describe the history and quality of the your relationship with your

Mother:

Father:

sibling(s) and extended family:

friends:

Children: How many children do you have? ______What are their ages? ______. Please describe your relationship with them:

Your current marital status: ______How many times have you been married? ____

If currently married, how long have you been married? ______How is the marriage? ______

If currently married, please describe the current marriage relationship by circling the following that apply:

verbal argumentsphysical violencename calling lack of respect

excessive workaffairslack of time together parenting disagreements

lovekindness respect displays of affection

quality time together common interestsfun other ______

School History

Have you ever been placed in special education? ___ if yes, what for what subjects ______

Have you ever failed or repeated a grade? ___ if yes, what grades ______

Have you ever had discipline problems in school? ____ if yes, what grades ______

If yes, please describe:

What is your highest level of education (e.g., college graduate, some college, GED)? ______

Work History

Are you currently employed? _____ If yes, where ______. How long? ______

Have you ever been fired from a place of employment? ___ If yes, where? ______

Please list other places you have worked (include the dates you worked there):

Does your spouse currently work? ____ If yes, were ______. How long? _____

Please list other places where your spouse has worked:

Parent Information

Please describe both of your parents education:

Work history:

Parents’ interest, hobbies, and activities:

Medical: Please describe any parent problems in any of the following:

Health:

Physical:

Emotional:

Thinking:

Behavioral:

Please describe any previous or current psychological treatments for either of the parents including any history of psycho-tropic medication:

Life Development

How would you describe your life, your family life, your relationships with others, academic functioning, etc., when you were a child, before going to High School?

How would you describe your life, your family life, your relationships with others, academic functioning, etc., when you were in High School?

How would you describe your life, your family life, your relationships with others, academic functioning, etc., after High School through the age of 30?

How would you describe your life, your family life, your relationships with others, etc., after the age of 30?

Describe any financial problems you currently have in your life:

Describe your legal history (if any):

If you have children, does any child in the family have behavior, academic, or emotional problems? _____ if yes, please describe:

Please list the names and ages of your children and where are they living now:

How do you get along with your children?

Please indicate which family members have experience any of the following. Please include and indicate parents (m for mother, f for father), step father (sf), step mother (sm), spouse (sp), child (c), sibling (s), maternal grandparent (mgf, mgm), paternal grandparent (pgf, pgm), maternal aunt (ma), maternal uncle (mu), paternal aunt (pa), paternal uncle (pu), maternal cousin (mc), and paternal cousin (pc):

anxiety ______depression ______anger control ______

bipolar disorder ______mood swings ______compulsive behaviors ______

panic attacks ______irritability ______aggression ______

sexual abusing others ______physically abusing others ______neglecting others ______

sexual abuse victim ______physical abuse victim ______neglected ______

mental problems ______hospitalized for emotions ______sleep problems ______

stealing ______lying ______setting fires ______

juvenile sentences ______arrested ______jail or prison time ______

destruction ______impulsivity ______hyperactive ______

inattentive ______learning problems ______sleeps too much ______

went to college ______dropped out of high school ______has lots of money ______

mentally retarded ______high blood pressure ______fatigue ______

drug use ______excessive alcohol use ______special education ______

running away ______extra marital affairs ______severe trauma ______

counseling ______psychosis (hallucinations) ______seizures ______

headaches ______personality problems ______bed wetting ______

Please describe any other family health problems that are not listed above:

Substance Use

Please give a history of your use of the following substances:

Substance Your age when Age at Ages when used Amount of use (frequency and amount)

first used. last use the most. when used the most.

cigarette smoking ______

chewing tobacco ______

alcohol ______

marijuana ______

cigarette smoking ______

energy drinks ______

caffeine pills ______

inhalants (gas, glue) ______

amphetamines (speed)______

diet pills ______

laxatives ______

cocaine ______

pain pills ______

opiates (heroin) ______

anxiety medications ______

ecstacy ______

“spice” ______

LSD ______

mushrooms ______

other ______

Have you ever had a DUI or DWI or any other driving while intoxicated offense? _____ If yes, how many? ___

Have you ever attended a 12 step program or another support group that was addiction related? ____ If yes, which support group? ______

What other information can you report about substance use?

Spirituality

Do you attend church? ______if yes, which church? ______and please describe your spiritual attitudes and views:

Please comment on anything else you feel is important: