Jeanne Holverstott, MS
Initial Paperwork
Today’s Date
Client Information / Financial Guarantor (If Different from Client)Name / Name
DOB / Address
Phone
Address / Phone
Email / Relationship to Client
Concerns Leading to Today’s Appointment
Whom May I Thank for This Referral?
Marital History
Marital Status: single separated living together married divorced other
Number of Children:
Persons in the Family / Relationship / Location
Educational History / High School / Trade/Technical / Jr. College / College
Name
Years Completed?
Did you graduate?
If incomplete, why?
Employment History / Position / From / To / Reason for Leaving
Please Check Any of the Following That Pertain To You
Aggressive Thoughts / Food Restriction / Learning Problems / Seeing Visions
Alcohol Use / Guilt / Loneliness / Self Injury
Anxiety / Headaches / Mood Swings / Sexual Problems
Appetite Changes / Hearing Voices / Nervousness / Sleep Changes
Bingeing / Homicidal Thoughts / Nightmares / Stomachaches
Confusion / Hopelessness / Obsessive Thoughts / Stress
Daytime Napping / Hyper-sexuality / Panic Attacks / Suicidal Thoughts
Depression / Inability to Sleep / Paranoia / Tiredness
Dizziness / Inattention / Poor Memory / Unhappiness
Drug Use / Involuntary Movement / Purging / Vivid Dreams
Eating Problems / Irritability / Racing Thoughts / Weight Gain
Excessive Sleep / Low Interest in Activities / Restlessness / Weight Loss
Psychiatric History / No / Yes / Describe
Have you ever received psychological help or counseling of any kind before?
Are you currently being treated for a psychiatric illness?
Please list any suicide attempts
Has anyone related to you committed suicide or attempted suicide?
Please list all psychiatric or
therapeutic treatment on either outpatient or inpatient basis / Date / Hospital or Clinician / Reason
Are you taking any medications? / Yes / / `No / / Name:
Purpose:
Name:
Purpose:
Name:
Purpose:
Have you taken any medications in the past? (If so, please list) / Yes No / Name:
Purpose:
Name:
Purpose:
Name:
Purpose:
Drug and Alcohol: List below all forms of alcohol, drugs and prescription drugs that you have ever used or abused
Type / Amount / First Use / Last Use
Alcohol
Marijuana
Cocaine
Methamphetamine
LSD/Opiates/Heroin/IV Drugs
Other
Caffeine
Nicotine
Have you been diagnosed with an Autism Spectrum Disorder?
Yes No / In her practice, Jeanne uses the words autism, Asperger’s, and Autism Spectrum Disorder. Do you have any concerns using this terminology?
Yes No / If “yes”, please explain:
What do you hope to achieve from working with Jeanne?