Lydia Byhardt Bollinger, MSW

Lydia Byhardt Bollinger, MSW * Licensed Clinical Social Worker

* * 971-409-5613

Adult History Form

Name Age Birth date

Occupation Employer

Marital StatusName of Spouse/Partner

How Long Have Both of You Been Together? Religion

Last Medical Examination:Reason:

Primary Medical Provider:

Current health concerns:

If you take more medications than space allows, please continue on the back of the page.

Have You Ever Been Hospitalized for a Physical Illness? NoYes - Describe:

Personal or Family History of:

Involvement with law:

Anyone in family use: DrugsTobacco Alcohol

Personal or Family history of:

Mental health concerns

Medical concerns

Abuse (physical, sexual, verbal)

Serious loss (such as death in family, frequent moves, divorce, physical separation from important person, change in health)

Trauma (Such as car accident, physical injury, physical/emotional/sexual abuse)

Describe:

Have you ever been diagnosed or hospitalized for Depression, Anxiety Disorder, ADHD, Schizophrenia, etc? No Yes - Describe:

Rate Any of the Following That May Apply to You:

0-None 1-Mild 2-Moderate 3-Severe

History of

Counseling: IndividualCouplesFamily Outpatient Group Counseling

Day TreatmentInpatientPsychiatric ER

When and Number of Sessions:

Was it a positive experience? What did or did not work for you?

Current Stresses:

Anything else you want me to know?

What do you wish to Achieve with Coaching/Therapy?