David Tredinnick, PsyD
CONFIDENTIAL CLIENT INFORMATION QUESTIONNAIRE
Please indicate your current relationship status:
❑ Single❑ In a Committed Relationship❑ Living with Partner❑ Married❑ Separated
❑ Divorced❑ Widowed❑ Other:______
Racial/ethnic Background:
❑ White/Caucasian ❑ African-American ❑ Black ❑ African ❑ Asian-American ❑ Asian or Pacific Islander ❑ Hispanic-American
❑ Latino/Latin American/Hispanic ❑ Arab-/Middle Eastern-American ❑ Arab/Middle Eastern ❑ Native American/Alaskan Native ❑ Multiracial Specify:______❑ Other Specify: ______
Religious preference: ______Are your currently active in your religion? ❑ Yes ❑ Somewhat ❑ No
Sex at Birth❑ Female ❑ Male ❑ Other ______Self-identify Gender Identity ❑ Male ❑ Female ❑ Transgender ❑Other ______
Sexual Orientation: ❑ Straight ❑ Gay ❑ Lesbian ❑ Bisexual ❑ Queer ❑ Prefer not to say ❑Other ______
Country of origin ______
Place of Residence: ❑ Alone ❑ With Family ❑ With Roommates ❑ With spouse/partner
Hours employed per week: ______Place of employment: ______
PHYSICAL HEALTH:
Do you have health insurance with mental health coverage? ❑ Yes ❑ No ❑ Uncertain Insurance Company: ______
How is your physical health at present? ❑ Poor ❑ Unsatisfactory ❑ Satisfactory ❑ Good ❑ Very good
Please list any persistent physical symptoms or health concerns (e.g. chronic pain, headaches, hypertension, diabetes, etc.): ______
Are you having any problems with your sleep habits? ❑ No ❑ Yes (If yes, check where applicable):
Are you having any difficulty with appetite or eating habits? ❑ No ❑ Yes (If yes, check where applicable):
❑ Eating less ❑ Eating more ❑ Bingeing ❑ Restricting ❑ Purging/Vomiting❑ Significant weight change (last 2 months)
Are you currently seeing a psychiatrist or have you seen a psychiatrist in that past? ❑ Yes ❑ No
If yes, where: ______When: ______Duration: ______
What was the focus of the psychiatric treatment? ______
Were you prescribed psychiatric medications? ❑ Yes ❑ No What medications? ______
FAMILY BACKGROUND:
Please list the members of your family (including parents, step-parents, spouses/partners, and children), their genders, their occupations and their ages (e.g. father, M, Lawyer, 42; sister, F, teacher 29; son, M, student,12; partner, M, doctor, 35):
Family Member OccupationAge
______
______
______
______
______
______
Please check any past, present, or impending special problems in your family:
❑ deaths
❑ divorce
❑ frequent relocations
❑ debilitating injuries/disabilities
❑ alcohol/drug abuse
❑ serious illness
❑ psychiatric disorder
❑ physical/sexual abuse
❑ financial crisis/unemployment
❑ legal problems
❑ attempted/completed suicide
❑ eating disorders
❑ other______
MENTAL HEALTH HISTORY:
Have you ever been a victim of:
❑ Emotional abuse as a child❑ Physical abuse as a child❑ Sexual molestation/abuse as a child
❑ Emotional abuse by a partner/spouse❑ Physical abuse/assault by a partner/spouse❑ Sexual abuse/assault as an adult
❑ Other Trauma Specify: ______
How often are you having suicidal thoughts presently? ❑ Frequently ❑ Sometimes ❑ Rarely ❑ Never
How often have you had suicidal thoughts in the past? ❑ Frequently ❑ Sometimes ❑ Rarely ❑ Never
How often are you having thoughts of harming others presently? ❑ Frequently ❑ Sometimes ❑ Rarely ❑ Never
How often have you had thoughts of harming others in the past? ❑ Frequently ❑ Sometimes ❑ Rarely ❑ Never
Have you ever intentionally inflicted any harm upon yourself? ❑ Yes ❑ No ❑ Unsure
Have you ever attempted suicide? ❑ Yes ❑ No Date(s) ______
Have you ever been hospitalized for psychological reasons? ❑ Yes ❑ No Date(s) ______
Reason: ______
ALCOHOL AND OTHER DRUG USE:
How often do you drink alcohol?
❑ Daily ❑3 or more times per week ❑ 1-2 times per week ❑ Weekly ❑ Monthly ❑ Less than monthly ❑Never
How often do you use other drugs (marijuana, cocaine, ecstasy, oxycotin, etc)?
❑ Daily ❑3 or more times per week ❑ 1-2 times per week ❑ Weekly ❑ Monthly ❑ Less than monthly ❑Never
PROBLEM ANALYSIS:
Briefly describe the problem you most wish help with right now: ______
______
______
How would you rate the intensity of the problem or concern that brought you in? (Circle the appropriate number)
1 2 3 4 5 6
Not Intense Moderately Intense Extremely Intense
Approximately how long have you had the current problem? ______
In what ways have you attempted to cope with this problem? ______
______
Please read this checklist and check the items that YOU WOULD LIKE TO DISCUSS with your counselor.
_____Major/Career concerns
_____Academic difficulty
_____Test or speech anxiety_
_____Study habits or time management
_____Adjustment to college
_____Romantic relationship
_____Relationship w/ parents/family
_____Relationship w/ roommates
_____Relationship w/ friends
_____Feeling dependent on others
_____Dating and/or social skills
_____Shyness
_____Feeling isolated or lonely
_____Fear of close relationships
_____Breakup of intimate relationship
_____Motivation
_____Difficulty making decisions
_____Procrastination
_____Depression
_____Unhappy much of the time
_____Dislike myself
_____Self-confidence
_____Feeling unworthy, inferior, guilty
_____Sleep problems
_____Eating/appetite problems
_____Grief/loss
_____Stress
_____Suicidal thoughts/behaviors
_____Self-harm thoughts/behaviors
_____Thoughts of harming others
_____Anxiety, worrying
_____Specific fears or phobias
_____Difficulty asserting myself
_____Out of touch with my feelings
_____Confused about beliefs/values
_____Dealing w/ anger/irritability
_____Difficulty expressing my feelings
_____Eating disorder
_____Weight problems
_____Physical appearance
_____Physical stress (headaches, etc.)
_____Concerns about health
_____Physical handicap or disability
_____Chronic physical symptoms
_____Physical or sexual abuse
_____Pregnancy (yours or partner’s)
_____Sexuality
_____Sexual orientation
_____Alcohol problems
_____Drug problems
_____Financial difficulties
_____Arrest or legal problems
_____Gambling/gaming
_____Other: ______
How many counseling sessions do you anticipate needing? ❑ 1 ❑ 2-3 ❑ 4-6 ❑ 7-9 ❑ 10-12 ❑ 12-15 ❑ 16+
SIGNATURE:I verify that the above information is accurate to the best of my knowledge.
______
Client SignatureDate
INFORMED CONSENT FORM
David Tredinnick, PsyD
CONFIDENTIALITY
I adhere to very strict confidentiality standards, in accordance with Florida Law, and maintain confidentiality about the fact that you are in counseling, the information you disclose in counseling, and your counseling records. If you want me to provide information about your counseling to people other than myself, I will do so with your written authorization. You should be aware that I may be required to disclose client information, even without consent, in the following situations:
•When doing so is necessary to protect you or someone else from imminent physical and/or life-threatening harm.
•When a client lacks the capacity or refuses to care for him/herself and such lack of self care presents substantial threat to his or her well-being.
•When the abuse, neglect, or exploitation of a child, elder adult, or dependent adult is suspected.
▪Examples of abuse, neglect, or exploitation include, but are not limited to, violence towards a minor, a minor witnessing violence or being in the presence of violence, drug use in front of or while caring for a minor, or financial exploitation of an elder adult. Examples also include incidents of past abuse, including those described above, if the alleged perpetrator of abuse is currently in a caretaker capacity with or is still present in the home of a minor, elder adult, or dependent adult.
•When a client pursues civil or criminal legal action against me or when a client makes a complaint to a Professional Board.
•When a client is involved in a legal proceeding and there is a court order for the release of the client’s records.
•In accordance with the Patriot Act, the I may disclose a client’s mental health information to authorized federal officials, who are providing protective services to the President of the United States and other important officials, or to authorized federal officials who are conducting national security and intelligence activities. By law, I cannot reveal to the client when we have disclosed such information to the government.
In addition, you should be aware of the following limits to confidentiality: 1) Information that you allow me to exchange with other professionals or information you might choose to provide to me via e-mail, fax, or cordless phones cannot be guaranteed confidential. 2) Personal and confidential information is stored in a locked filing cabinet, but it is possible that this information could be accessed illegally by others.
Clients should also be aware that, under some circumstances, the Florida Bar, various federal agencies, and some other licensing bodies may require counseling records prior to taking the bar exam, being licensed, or being employed. If you have any questions about confidentiality, you may ask me
BENEFITS AND RISKS
Counseling has both benefits and risks. It is an active and cooperative effort involving both the client and counselor. Counseling may result in better emotional and mental health and positive changes in behaviors and coping ability. However, through the normal process of counseling and discussing your personal concerns, you may experience greater emotional distress at times. You also may find that positive changes you make may result in a change in the relationships in your life (e.g., gaining relationships, becoming closer in relationships, losing relationships, or relationships feeling more distant). If you have any concerns about your progress or the results of your counseling, I encourage you to discuss them with me at any time.
Please sign below to indicate that you have read and fully understand this form and voluntarily agree to participate in counseling services.
Client Name (Please Print)______Signature______/ Date ______
FINANCIAL CONTRACT
David Tredinnick, PsyD
This contract outlines my financial business policies. By signing this contract, you accept it’s conditions. Please elect which method of payment you will be using:
❑ Self-pay or use of out-of network benefits (Fill out Section 1 only)
❑ Insurance (Cigna or Humana) (Fill out Section 2 only)
No Show Policy
Please understand that last minute cancellations and no-shows prevent others from obtaining much needed services. By signing this contract, I understand that since my appointment time has not been set aside exclusively for me, that I am responsible for notifying my practitioner 24 hours in advance. Failure to give proper notification will result in a charge of the entire amount of the session based on your self-pay rate or Dr. Tredinnick’s contracted rate with your insurance company.
Client’s Signature: ______Date: ______
Therapist: ______Date ______