M. J. Murphy Counseling Services, Inc.

1455 Lincoln Parkway, Suite 240 ~ Atlanta, GA 30346 ~ Phone 678-793-5014

e-mail

Personal Data Form

The information requested below is to help me understand you and your concerns. Information will be held in confidence. You may want to write on the back of a page to answer some questions. If you prefer to discuss certain issues in person, write “discuss later” beside that item.

Today’s Date ______Date of Birth______Age______

Name______

LastFirstMiddle Nickname or Preferred Name

Home Phone ______Work ______Cell ______

Address______

StreetCityStateZip

Single_____ Married____ Separated____ Divorced____Widowed____ Significant Other/Partner ____

Family Physician______Date of Last Exam ______

Employer______Full Time___ Part Time_____

Occupation ______E-mail address______

Referred to Mary Jane Murphy by ______

May I thank this person for the referral?YESNO

Are You Currently Involved in Any Legal Action? YESNO

Do you expect to have any significant upcoming Legal Action? Describe. (for example, divorce or child custody issues)______

MEDICAL HISTORY

What are any significant medical conditions you have, past or present?______

______

Current MedicationsFor What ConditionPrescribed By

______

______

______

______

Previous TherapistsDatesFor What Concerns

______

______

______

Are You Seeing Another Therapist Presently? If so, provide name______

How much alcohol do you consume weekly? none2-4 drinks5-10 drinksmore than 10 drinks

Do you think you have a problem with alcohol or drugs?YESNO

Have other people told you that they think you have a problem in this area?YESNO

Was there a time n your life when you drank more than you do now?YESNO

Do you use any other substances, such as prescription or recreational drugs, to feel better?YESNO

Personal Data Form (2)

FAMILY HISTORY

Mother’s Name______Age_____ Deceased______

date

Did you live with her growing up? YES NO

Any mental illness?YESNO

Any substance abuse?YESNO

Any other abuse?YESNO

Father’s Name______Age______Deceased ______

date

Did you live with him growing up? YES NO

Any mental illness?YESNO

Any substance abuse?YESNO

Any other abuse?YESNO

Brothers / Sisters

NameAge Sex Deceased? Date

______

______

______

______

Any substance abuse by siblings? YESNO

Any other abuse by siblings?YESNO

List the friends you view as your core support system:______

______

______

List the family members you view as part of this core support system:______

______

______

Are you currently in a marriage or other long term relationship? If so, please describe ______

______

______

Describe any previous marriage or long term relationship______

______

______

Children in Order of Birth

NameAge Sex(Deceased? Date)

______

______

______

Any substance abuse with children?YESNO

Any medical issues, emotional problems or learning disabilities with children?YESNO

If so, please describe______

Personal Data Form (3)

Briefly describe your faith history. Were you raised to practice a particular religion? Do you currently have spiritual practices that serve as a resource for you? Have you experiencedany changes or loss of meaning in this area? What makes life meaningful to you?

______

______

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PRESENT CONCERNS

Circle the Word That Best Describes Your PHYSICAL Condition At This Time

POORFAIRAVERAGEGOODEXCELLENT

Circle the Word That Best Describes Your EMOTIONAL Condition At This Time

POORFAIRAVERAGEGOODEXCELLENT

What do you see as your personal strengths and what has worked in the past to help you cope?______

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______

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What are your main reasons for seeking counseling at this time?

_____ ALCOHOL OR DRUGS_____ LOSS OF MEANING_____ RELIGIOUS DOUBTS

_____ ANGER_____ MARITAL CONCERNS_____ SELF-DOUBT

_____ ANXIETY_____ MOOD SHIFTS _____ SELF-ESTEEM

_____ DEPRESSION_____ NERVOUSNESS _____ SLEEPING PROBLEMS

_____ EATING PROBLEMS_____ PARENTING CONCERNS_____ SEXUAL ABUSE

_____ EMOTIONAL ABUSE_____ PANIC ATTACKS_____ SEXUAL PROBLEMS

_____ FATIGUE_____ PHOBIAS_____ STRESS

_____ FEAR_____ PHYSICAL ABUSE_____ SUICIDAL FEELINGS

_____ GRIEFRELATIONSHIP WITH:_____ VOCATIONAL ISSUES

_____ GUILT_____ CHILDREN

_____ HOPELESSNESS_____ SIGNIFICANT OTHER

_____ LONELINESS_____ PARENTS

_____ OTHER ______

Has something happened recently to worsen any of these symptoms? ______

______

Please state in your own words the concerns you bring to counseling at this time. ______

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Do you have any desired goals for counseling? If so, what are they? ______

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