Pamela M. Barnett, LPC, NCC
3 Dunwoody Park South, BLGE 3, Ste 103
Dunwoody GA, 30338
Phone: 678-858-0630
ADULT HISTORY
Client Name: ______Date: ______
PRESENTING PROBLEMS
What brings you to therapy?
How long have you had these problems/symptoms?
Have you had prior psychotherapy? Circle: Yes or No
If yes, please provide your prior provider’s name, address, dates and duration of treatment.
Have you taken or are currently taking any psychotropic medication? Circle: Yes or No
If yes, please list your medications including name, dosage, start and/end date, and the physician who prescribed it to you.
List the name, address and phone number of your primary care physician and/or psychiatrist.
Has any family member had any mental health treatment or diagnosis? If yes, please list their relationship to you and what you may know of their diagnosis.
Do you have a history of trauma? Trauma includes incidents such as sexual abuse/assault, car accidents, combat experiences as examples. Please indicate the trauma, date, or age which it/they have occurred without detail.
Family of Origin
Who raised you from childhood?
Describe your parents or caregivers. Are they still alive, still married, remarried, or divorced and how many times? What is/was their occupation and/or education level? What is their general health?
Please indicate any siblings, gender and ages.
Immediate Family
What is your marital status? Any divorces, prior marriages, partners? Please list all and duration.
Do you have any children? List gender and ages, biological or step-children, and from what relationship(s)?
Medical History
Describe your current physical health (good, fair, poor) and indicate any health conditions or concerns.
List any and all medications you are currently taking, why you are taking it, date and name of the physician who prescribed it to you.
Substance Use History
Family alcohol/drug abuse history. Anyone in your family of origin or immediate family currently uses any substances or has a substance use history?
Please list any substances that you have used or currently use. Please indicate the substance used, the age you first used/tried the substance, current use, amount and frequency. Substances include alcohol, abuse/addiction to illegal or prescription drugs, marijuana, etc. Please also list any and all inpatient/outpatient treatment, rehab treatment, location and dates.
Legal History
Do you currently have or have had any legal problems? Now on parole/probation, arrest not substance related, arrest substance related, jail or prison time? Court ordered to be in therapy? Please list or indicate none.
Employment
Are you currently employed? How satisfied are you with your job? Any co-worker or supervisory conflicts? What type of work do you do?
Military History
Are you currently serving in the military or have served in the military? What branches, periods of time served, MOS, and have you served in any wars, conflicts, or had any incidents and/or disciplinary actions?
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