Dr. Reneé Roberts, Psychologist

Dr. Reneé Roberts, Psychologist

Century Plaza, 281 W. 24th St., Ste 147, Yuma, AZ 85364

Office: 928-317-8800 Cell: 928-750-3353

INTAKE QUESTIONNAIRE

Please complete questions as you can, and bring completed form to the Intake appointment.

CLIENT NAME: ______Date: ______

Client phone number(s) : ______

___ Yes ___ No Okay to leave phone message reminder of appointments?

Referred by: ______

PRESENTING CONCERNS / CHIEF COMPLAINT

What are you seeking help for today? ______

______

DURATION How long have these issues been a concern? ______

FREQUENCY How often are these an issue for you? ______

How do these concerns affect your daily living and your family / significant others?

______

HISTORY OF PRESENT ILLNESS

What has been done so far to address these concerns? ______

______

What seems to help? ______

______

What makes it worse? ______

______

How will you know if things are better / improving? ______

______

What type of assistance do you (or others) think you need? ______

______

Current Stressors

______

SYMPTOMS

Check all that apply

Depression:

___ Depressed Mood

___ Sleep Disturbance

___ Anhedonia / lack of pleasure in life

___ Inappropriate Guilt

___ Worthlessness

___ Decreased energy

___ Appetite disturbance

___ Physical agitation

___ Physically very “still”

___ Suicidal ideations

___ Decreased concentration / Indecisiveness

Mania:

___ Elevated Mood

___ Irritable Mood

___ Grandiosity

___ Decreased need for sleep

___ Racing thoughts

___ Distractibility

___ More talkative / pressured speech

___ Increase in goal-directed activity / psychomotor agitation

___ Excessive involvement in pleasurable activities with painful consequences (buying sprees, sexual indiscretions, foolish business investments, binges of alcohol/drugs)

Anxiety:

___ agoraphobia

___ panic attacks

___ derealization

___ depersonalization

___ muscle tension

___ feeling on edge / keyed up

___ fatigue

___ irritability

___ sleep disturbance

___ difficulty concentrating

___ excessive anxiety / worry

Obsessions/Compulsions:

___ obsessive thoughts, impulses, images

___ compulsive, repetitive behaviors (hand washing, checking, counting, repeating words)

Psychosis:

___ delusions

___ hallucinations

___ paranoia

PTSD:

___ involved in traumatic event

___ response of fear / helplessness / horror

___ recurrent intrusive recollections of the event

___ recurrent distressing dreams of the event

___ psychological distress at exposure to cues

___ physiological reactivity on exposure to cues

___ efforts to avoid thoughts/feelings about the event

___ efforts to avoid people / places / activities associated with the trauma

___ inability to recall aspects of the trauma

___ flashbacks

___ anhedonia or lack of pleasure

___ detachment

___ restricted range of emotions

___ sense of foreshortened future

___ sleep disturbance

___ irritability / anger

___ difficulty concentrating

___ hypervigilance

___ exaggerated startle

How well are you able to complete activities of daily living? (e.g., bathing, eating, dressing, household management, homework, chores). Explain any difficulties, including any assistance required.

______

MEDICAL HISTORY QUESTIONNAIRE

Any major health / medical problems? ______

______

___ Yes ___ NoAre you currently taking any medications? (prescription, over the counter

vitamins, homeopathic or naturopathic remedies, traditional or alternative medicine

remedies, herbs)

Name of Medication Reason for Taking Medication

______

Describe any side effects that you find troublesome from any of the medications you are currently taking.

______

___ No ___ Yes Do you have any abnormal / unusual muscle movements?

___ No ___ YesAre you allergic to any medications? Which ones? ______

______

___ No ___ YesDo you have any other allergies? ______

______

When was the last time you saw your primary care physician and what was the purpose of that visit?

______

___ No ___ YesDo you have any history of head injury with concussion or loss of

consciousness?

Are you currently pregnant? ___ No ___ Yes ____ Unsure ___ N/A

CRIMINAL JUSTICE

___ No ___ Yes Are you currently involved with the legal system? (e.g., probation,

parole, jail, pending charges, court-ordered treatment, arrests)

___ No ___ Yes Any past involvement with the legal system?

___ No ___ Yes Do you have a Probation/Parole Officer? If “yes” make sure

the Officer’s name and phone number is recorded on the Cover Sheet.

SUBSTANCE RELATED DISORDERS

ALCOHOL

What are your drinking habits? How much, how often and what do you drink?

______

___ No ___ Yes Do you now, or have you ever had a problem with alcohol or drugs?

___ No ___ Yes Is a spouse / significant other or family member concerned about

your use of alcohol or drugs?

___ No ___ Yes LOSS OF CONTROL Do you ever drink more than you meant to?

___ No ___ Yes URGES Feel preoccupied with wanting to drink?

___ No ___ Yes Have you neglected some of your usual responsibilities in order to

drink?

___ No ___ Yes Unsuccessful Efforts to Control Use: Have you felt you wanted or

needed to cut down on drinking or tried to stop but could not?

___ No ___ Yes Important activities given up or reduced in order to drink?

___ No ___ Yes Great deal of time spent in obtaining/using substance?

___ No ___ Yes Tolerance? (Can really hold your liquor)

___ No ___ Yes Withdrawal / Hangovers?

___ No ___ Yes Continued use despite knowledge of having physical /

psychological problem caused / exacerbated by alcohol?

SUBSTANCE RELATED DISORDERS

ILLEGAL DRUG USE / ABUSE OF PRESCRIPTION MEDICATIONS

____ No ___ Yes Have you used illegal drugs in the past?

____ No ___ Yes Do you use illegal drugs, or take more medicine than prescribed?

____ No ___ Yes Do you ever use more than you meant to, or feel preoccupied with

buying drugs or using drugs?

____ No ___ Yes Have you neglected some of your usual responsibilities in order to

use?

____ No ___ Yes Have you felt you wanted or needed to cut down or tried to stop

but could not?

____ No ___ Yes Have you given up or reduced important activities in order to buy

or use drugs?

___ No ___ Yes Will you drink / use when you leave here today?

___ No ___ Yes Have you ever abstained on your own before?

When & for how long? ______

How did you do it?______

Complete the table below for each substance used

SUBSTANCE USE
CIRCLE IF USED IN PAST 12 MONTHS / How Often? / Route / Age
First Used / When Last
Used / Amount Used past 30 days
(0201) Alcohol
(0401) Marijuana
Stimulants
(1001) Methamphetamine
(0302) Cocaine/crack
(1201) Other (e.g., Ritalin, amphetamine)
Opiates/Narcotics
(0501) Heroin
(0706) Other (e.g., codeine, hydrocodone, oxycodone, oxycontin, propoxyphene, non-prescription methadone)
Depressants
(1308) Benzodiazepines (e.g., Valium, Klonopin, Ativan, Xanax, Halcion)
(1605) Other sedatives, tranquilizers hypnotics (e.g., Soma, Benadryl, barbiturates)
(0902) Hallucinogens: LSD, PCP, MDMA, shrooms, ecstasy, ketamine, psilocybin, etc.
(1703) Inhalants: glue, paint, gasoline, aerosols, etc.
(2002) Other Drugs:
non-narcotic analgesics, GHB, and other medications used in excess of prescription [e.g., Prozac, Haldol, Robitussum]
Specify type:______

LIVING ENVIRONMENT

Briefly describe where you live and with whom. ______

______

____ No ___ Yes Have you recently experienced any significant change in your

living environment / situation (e.g., removal from family, divorce,

adoption, school suspension, family death, auto accident, loss of job/income)?

If yes, how have you dealt with this issue?

______

FAMILY / COMMUNITY INVOLVEMENT

Current family (married, children?) ______

______

Family History (family circumstances including composition of family) ______

______

Past Psychiatric History

___ No ___ Yes Psychiatric In-patient

___ No ___ Yes Out patient Counseling

Family Psychiatric History ______

Sexual History (anything I need to know?) ______

In general, how do you get along with others? ______

STRENGTHS / Talents / Skills / Abilities: ______

______

Is there anything about you, your family or your culture that would help us understand you, and how people respond to you?

______

EDUCATIONAL/VOCATIONAL TRAINING

Highest Grade completed: ______

___NO ___ YES Are you currently involved in an educational or vocational training

program?

___ NO ___ YES Are you interested in becoming involved in an educational or

vocational training program?

___ NO ___ YES Have you ever been told you have special educational needs?

EMPLOYMENT

___ No ___ Yes Financial concerns?

___ No ___ Yes Are you currently working (full, part-time or volunteer)?

Doing what?

______

If no, when was the last time you worked? ______

What prompted the change? (e.g., reasons you left that job)

______

___ No ___ Yes Are you interested in finding employment?

___ No ___ Yes Any military service? What? ______

___ No ___ Yes Is the complaint deployment related?

Deployment History:

______

PROBLEM GAMBLING

____ No ___ Yes Do you gamble?

____ No ___ Yes Have you ever felt the need to bet more and more money?

____ No ___ Yes Have you ever had to lie to people important to you about how

much you gambled?

ABUSE / SEXUAL RISK BEHAVIOR

___ No ___ Yes Do you feel safe in your current living situation?

___ No ___ Yes Do you feel safe outside of your home? If no, briefly explain.

___ No ___ Yes Are you currently or have you ever been hurt, harmed, touched

inappropriately, or abused by someone in any way?

___ No ___ Yes Is any member of your household / family currently being or has

ever been harmed, abused, neglected, or victimized?

___ No ___ Yes Do you engage in any sexual behaviors that you are concerned

about, or that have raised concerns in your family or community

___ No ___ Yes Do you think the issues identified above affect you now?

RISK ASSESSMENT

___ No ___ Yes Have you ever thought about harming yourself or someone else?

___ No ___ Yes Did you have a plan?

When was the last time you thought about harming yourself or

someone else?

______

___ No ___ Yes Have you ever harmed / injured yourself intentionally?

___ No ___ Yes Have you ever harmed / injured others deliberately?

___ No ___ Yes Did you have a plan?

When was the last time you actually harmed yourself or someone

else deliberately?

______

___ No ___ Yes Do you have goals for the future? What are they? ______

______

Risk of Harm to Self

___ No ___ Yes Prior suicide attempt
___ No ___ Yes Repeated attempts; increasing severity
___ No ___ Yes Stated plan with intent
___ No ___ Yes Access to means (e.g., weapon)
___ No ___ Yes Substance use (current/past)
___ No ___ Yes Other self-abusing behavior e.g. self-mutilation
___ No ___ Yes Recent losses / lack of support
___ No ___ Yes Behavioral cues (e.g., isolation, impulsivity, withdrawn, angry, agitated)
___ No ___ Yes Family history of suicide
___ No ___ Yes History of suicide in friend
___ No ___ Yes Terminal physical illness

Risk of Harm to Others

___ No ___ Yes Prior acts of violence
___ No ___ Yes Recent Fire setting
___ No ___ Yes Angry mood / agitation
___ No ___ Yes Recent Arrests for violence
___ No ___ Yes Prior hospitalizations for dangerousness
___ No ___ Yes Access to means (e.g., weapon)
___ No ___ Yes Substance use (current/past)
___ No ___ Yes Physically abused as child

TREATMENT PLAN

CLIENT’S TREATMENT EXPECTATIONS: ______

______

TREATMENT GOAL(S): ______

______

Client’s signature: ______Date: ______