Initial Intake History for Adults

Initial Intake History for Adults

Identifying Data:Date(s) of Evaluation: ______

Name:______

Date of Birth: ______Age: _____Sex: _____

Spiritual/Religious Beliefs: ______

Marital Status:______

Please circle if you are: Gay Lesbian Trans Bisexual Other

If so, please indicate what pronoun you go by: ______

History:

If married/dating/living together, describe the relationship (include names, occupation, and age of significant other, as well as history of the relationship):______

______

______

Previous marriages for either? (If so, please provide details)______

Do you have any children? (If so, please give names, sex, age, grade, and indicate with whom they live) ______

______

Description of Presenting Problem/Issue:

State in your own words the nature of your problems (i.e., What brings you in today? Why now?):

______

______

When did the problem begin?

______

What else was going on at the time? ______

______What solutions to your problems have been most helpful?

______

Treatment Expectations:

What were you hoping to accomplish during counselling? What do you think counselling is all about?______

______

How long do you think it will it take for you to get better? ______

______How will you and I know when we are finished? ______

______

Treatment History:

Have you been in therapy before or received any prior professional assistance for your problems? If so, list name (s), professional title(s), and dates of treatments and results:

______

Please list all prescription medications you are currently taking (including medications “as needed”, birth control, etc.). Include the dosage taken per day and the reason for taking the medication.

MedicationDosageReason

______

Do you have a family physician?_____ Yes_____ No

If yes, please give his/her name(s) and telephone number(s)

______

Have you spoken to your family doctor about the nature of your difficulties?_____ Yes_____ No

Are there any other significant health problems/accidents that have not been discussed so far?

_____ Yes_____ No

If yes, please describe? ______

______

Have you ever been hospitalized for psychological problems?_____ Yes_____ No

If yes, when and where? ______

Have you ever attempted suicide?_____ Yes_____ No

Do you smoke cigarettes?_____ Yes_____ NoNumber per day: ______

What are your current drinking habits? ______

When in your life were you drinking the most? ______

What was your drinking behaviour during that time? ______

Do you use street drugs, illegal, or recreational drugs? ______

If so, please list: ______

Have you ever been hooked on a prescribed medication or taken a lot more of it than you were supposed to?_____ If so, please list: ______

Family History:

Father’s Name: ______

Living ______Deceased ______

If living, present age? ______

If deceased, age at time of death? ______

How old were you at the time? ______

Cause of death: ______

Occupation: ______

Mother’s Name: ______

Living ______

Deceased ______

If living, present age? ______

If deceased, age at time of death? ______

How old were you at the time? ______

Cause of death: ______

Occupation: ______

Siblings:

Number of brothers ______Age(s) of brother(s) ______

Number of sisters ______Age(s) of sister(s) ______

Your place in family (e.g., 3rd of 4 children) ______

How did you get along with your siblings? ______

______

Has any relative attempted or committed suicide? ______

Does any member or your family suffer from alcoholism, depression, or anything that can be considered a mental disorder? ______

Were you raised by your parents?_____ Yes_____ No

If not, who raised you and between what years? ______

______

Give a description of your father’s (or father’s substitute) personality and his attitude towards you (past and present): ______

______

Give a description of your mother’s (or mother’s substitute) personality and her attitude towards you (past and present): ______

______

In what ways were you disciplined (punished) by your parents as a child? ______

______

Give an impression of your home atmosphere in the home in which you grew up (mention the state of compatibility between parents and children): ______

______

Did you experience any significant disruptions as a child? (e.g., separation from one or both parents for an extended time, significant geographical move): ______

______

If you have a step-parent, give you age when parent remarried ______

Has anyone (parents, relatives, friends) ever interfered in your life (e.g., marriage or occupation)? ______

Marriage/Common Law Relationships

What is your spouse’s /partner’s age? ______

Please describe your partner’s/spouse’s current or most recent (occupation): ______

______

What words best describe your spouse’s/partner’s personality? ______

______

In what areas are you compatible (e.g., shared interests)? ______

In what areas are you incompatible (e.g., sources of conflict)? ______

______

If Single:Is there any common pattern that seems to take place in many of your romantic involvements/relationships?

______Are you involved in a relationship now? If so, please describe your relationship: ______

______

Sexual Relationships:

Was sex discussed in your home? _____ Yes_____ No

Describe your parent’s attitude towards sex: ______

______Are there any relevant details regarding your first or subsequent sexual experiences? ______

______

Is your present sex life satisfactory? ______If not, please explain: ______

______Friendships:

How do you get along with peers? ______Who is your best friend? Why?______

______Were you ever bullied or severely teased? Describe: ______

______

Describe any relationship that gives you:

(a) Joy______

(b) Grief______

When was the last time you laughed?______Generally, do you express your feelings, opinions, and wishes to others in an open, appropriate manner? Describe those with whom (or those situations in which) you have trouble asserting yourself: ______

______Do you have at least one friend with whom you feel comfortable sharing your most private thoughts and feelings? _____ Yes _____ No (If yes, indicate number): ______

Are you currently troubled by any past rejections of loss of a love relationship? ______

Work History:

What type of work are you doing now? ______

Have you had any difficulty keeping long-term jobs? (If yes, please explain) ______

______Does your current family income feel adequate for your needs? (If no, explain): ______

Does your present work satisfy you? ______If not, please explain: ______

______

How do you get along with your Co-workers? Peers? Subordinates? Boss? ______

______What would you like to change about work? ______

______

Hobbies and Activities:

How do you spend your free time? ______

Do you keep yourself compulsively busy doing an endless list of chores? ______

Do you practice relaxation or meditation regularly? ______

Do you have trouble relaxing and enjoying weekends and vacations? (If yes, please explain)

______

Do you have any recurring dreams ______yes ______no

If yes, please describe them:______

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