David Phelan, M.C., L.P.C. 501 E. Litchfield Park, Suite B Litchfield Park, AZ 85340 623-330-3197

Adult history

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Personal Information

Date:

Name:

Age:

DOB:

Social Security or Insurance ID#:

Family and Living Situation

Household Members (Name, Age, Relation, Quality)

Name / Age / Relationship to client / Quality of relationship with client

Other immediate family not living at home

Name / Age / Relationship to client / Quality of relationship with client / Residence

Type of living situation (Apt, Single family home, condo, etc)

Any concerns about neighborhood?

Marital/Relationship Status:

Length of relationship and/or time since relationship:

Partner’s employment/education status (field, employer/school, length of time in field/school):

Other significant relationships (List previous spouses, fiancés, domestic partners)

Name / Age / Relation / Length & Time Since

Current relationship concerns (Please list details of concerns that cause conflict in the relationship: nature of the concern, frequency and duration of the concern)

Concern / Nature of Concern / Frequency and Duration
1. Children/ Parenting
2. Money
3. Time
4. Drugs/Alcohol
5. Arguing
6. Abuse
7. Sex/Intimacy

Employment

Please list your history over past 5 years, including work status (Employed, unemployed, self-employed, laid-off, contract, etc), type of work, length of each position

Religious Beliefs

What are the your/family’s religious beliefs?

Do you and/or your family attend church/synagogue/mosque?

If so, what church/synagogue/mosque:

Safety Concerns

Have you thought seriously about hurting or killing yourself or made an attempt?

If you have thought seriously about hurting or killing yourself or made an attempt:

How often have you thought seriously about hurting or killing yourself or made an attempt?

When have you thought seriously about hurting or killing yourself or made an attempt?

How long did the thoughts of self-harm last?

What your plan was (if any)?

What, if anything, kept you from your plan?

Have you thought seriously about hurting or killing anyone else or made an attempt?

If you have thought seriously about hurting or killing anyone else or made an attempt:

How often have you thought seriously about hurting or killing anyone else or made an attempt?

When have you thought seriously about hurting or killing anyone else or made an attempt?

How long did the thoughts of harm last?

What your plan was (if any)?

What, if anything, kept you from your plan?

Developmental History – Please indicate your history in relation to the following:

Prenatal and Birth / Yes / No / Details
Prenatal stress or injury
Prenatal drug/alcohol exposure
Birth trauma (forceps, breech, etc.)
Anesthesia, pain medications complications experienced by mother
Anoxia (oxygen deprivation @ birth)
Premature/late delivery
Medical problems after birth
Other:

Birth weight:

If adopted, at what age:

Growth and Development

Typical / More / Less / Details
Activity level
Motor/coordination development
Infections/allergies
Emotional development
Behavior concerns
Handedness development
Appetite/digestion
Language/speech development

Physical Traumas

Yes / No / Details
Head injury (even minor falls, etc.)
Coma (loss of consciousness)
Accidents (list all)
High fever
Serious illness
Surgery
CNS infection
Drug overdose/poisoning
Recreational drug use related physical impairment
Anoxia
Stroke

Psychological Stress/Life Changes

Yes / No / Details
Death in family
Divorce/remarriage
Move/relocation
School change
Job change
Family member chronic illness

Symptom Checklist

Please check mark if the client and/or family member(s) (parents, grandparents, brothers, sisters, aunts, uncles, and/or children) currently experience or have a history of any of the following symptoms.

for / Client / for / Family
Symptom / History / Current / History / Current
Feeling Tense
Depressed
Always on the go
School/work problem
Impulsivity
Hyperactivity
Attention problems
Behavior problems
Vocal or motor tics
Sleep problems
Legal trouble
Headaches
Feeling lonely
Frequent illness
Repetitive thoughts
Repetitive behavior
Shy with People
Allergies
Asthma
Seizures/Epilepsy
Chronic pain
Food sensitivity
Head injury
Memory problems
Temper tantrums
Rages
Verbal Aggression
Physical Aggression
for / Client / for / Family
Symptom / History / Current / History / Current
Stubbornness
Addictions
Bowel disturbances
Chronic fatigue/FMS
Inferiority feelings
Dizziness
Fainting spells
Heart palpitations
Stomach trouble
Poor appetite
Picky eater
Nightmares
Alcohol/drug problem
Feeling panicky
Tremors
Suicidal ideas
PMS
Physical/sexual abuse
Over ambitious
Unable to relax
Can’t make decisions
Communication prob.
Problems at home
Financial problems
Any chronic illness
Other, specify:

Current Medications

Medication/Condition / Dosage and Frequency / When was it first prescribed? / Do you take it as prescribed? (Y/N)

Behavioral Health Medication and Treatment History

List any medications you have taken in the past for any mental health concern:

Medication / Dosage and Frequency / When was it first prescribed? / Did you take it as prescribed? (Y/N)

List any mental health services you have received in the past

Facility/Provider / Problem / Date / Was it helpful?

Childhood Difficulties

Please describe all stressful events, not listed above which you experienced as a child that you think may be impacting your situation currently. For each item identified, please provide details (date/year/age of onset, duration, frequency of episodes, intensity):

DRUG/Alcohol History

Drug / Date/Age of first use / Date/Age of last use / Amount of use in last month / Intoxication/excess in last month / Method-smoke, drink snort, IV
Caffeine
Alcohol
Tobacco
Over the counter sleeping aids
Marijuana
Other controlled substances

Trauma

Please list any traumatic events not identified above which you believe may be making your situation more difficult right now.

CURRENT NEEDS

Describe what led you to making the appointment for counseling. (Although many things may have happened prior to making the appointment, helped you to decide that day to make the appointment rather than any day before then?)

What do you hope to accomplish with the assistance of biofeedback, neurofeedback and/or counseling?

Interviewed by: David Phelan, L.P.C. Date:

(History - Adult 2011-09-28.doc, rev. 1/3/14) p. 2/9