R.A.A.P. Counseling and Consulting, LLC

Adult Client Information

R.A.A.P. Counseling and Consulting, L.L.C.

(Raising an Alternative Perspective)

DeShawn Williams, L.C.S.W.

ADULT CLIENT INFORMATION

Client: ______Today’s Date: ______

First Middle Last

Gender: M ___ F ____ Age: ____ Birth Date: ______SSN:______

Address: ______City, State, Zip: ______

Telephone(s): ______

(home) (cell) (work)

Email 1: ______Email 2:______

May we leave messages for you? ___ on home phone ____on cell phone ___ on work phone __ on email

Marital Status:

Single ( ) Married ( ) Partnered ( ) Separated ( ) Divorced ( )

Other (Specify ______

Gender: M ______F ______Trans ______Intersexed ______

Others Living in the home:

Name:
Age:
Relationship: / Name:
Age:
Relationship: / Name:
Age:
Relationship: / Name:
Age:
Relationship:

Emergency Contact: ______phone: ______Relationship: ______

Referred by: ______

Education / Occupation / Employer
Client

Insurance Information ( if using insurance, ATTACH COPY OF INSURANCE CARD)

Primary / Secondary
Insured Name ……………
Date of Birth ………………
Insurance ID no. ………….
Relationship to Patient ……
Address ……………………
City, State, Zip …………….
Employer …………………
Insurance Company Name
Address ………………….
Phone ………………….
Other Information ………. / ______
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______ / ______
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Insurance Authorization: I authorize the release of any medical or other information necessary to process a claim. I authorize payment of medical benefits to the provider of services.

______

Client or Authorized Person’s Signature Date

Person(s) Financially Responsible for Treatment:

______

Date

______

Date

Strengths and Issues

Describe the problem(s) that brought you here today:
What is going well in your life?

Check any of the symptoms that you are having:

Depression / Feeling hopeless
Extreme Sadness / Feeling tearful
Trouble concentrating / Change in sleeping habits
Memory problems / Lack of energy
Change in eating habits / Weight changes
Feelings of extreme happiness / Change in sexual interest or function
Trouble performing at your job / Problems getting along with friends or family
Lack of enjoyment of usual activities / Feeling stressed
Self-esteem problems / Easily irritated
Perfectionism / Feeling guilty
Obsessions or compulsions / Feeling nervous
Feeling fearful / Sudden feelings of panic
Physical complaints of pain / Muscle tension
Problems with anger / Acting violently
Thoughts of hurting yourself or others / Thoughts of killing yourself or others

HAVE YOU EVER BEEN IN COUNSELING BEFORE? ______Yes ______No

If you have been in counseling before, please describe it below. Start with the most recent time.

A. When did you have counseling? / Date(s):
Who did you see? / Name:
Explain what happened:
B. When did you have counseling? / Date(s):
Who did you see? / Name:
Explain what happened:

Family History

Is there any family history of (circle all that apply):

Depression Alcoholism Substance Abuse Eating Disorders Anxiety

Physical Abuse Sexual Abuse Emotional Abuse Severe Mental Illness

Suicide/Gestures Homicide Abandonment Foster Care Involvement

Major Medical Problems Divorce Compulsive Behaviors

MEDICAL INFORMATION

Have you seen a doctor within the last year? Yes [ ] No [ ]
Why have you seen a doctor?
Who is your Doctor? Phone:
Are you taking any medications, prescription or over-the-counter? Yes [ ] No [ ]
Please describe:

Partner 1: SUBSTANCE ABUSE HISTORY

Do you use / have you used tobacco (any form)? / Current [ ] / Past [ ] / No [ ]
Do you use / have you used alcohol? / Current [ ] / Past [ ] / No [ ]
Do you use / have you used caffeine (any form)? / Current [ ] / Past [ ] / No [ ]
Do you use / have you used other mind altering substances
(drugs)? / Current [ ] / Past [ ] / No [ ]

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