Victoria S. Young, LCSW-C
8 Reservoir Circle, Ste. 103
Baltimore, MD 21209
410-303-1927
Date:______
Last Name:______First Name:______
Age:______Date of Birth:______Gender:______
SS# (Insurance Patients Only):______
Street Address:______
City: ______State: ______Zip Code: ______
Email: ______Is it OK to receive emails from me? Yes___ No____
Home Phone: ______OK to leave message? ______
Cell Phone: ______OK to leave message? ______
Work Phone:______OK to leave message? ______
Name of Emergency Contact:______Relationship to you:______
Address: ______
Home Phone: ______Cell/Work Phone: ______
Insurance Carrier for Mental Health: ______
ID Number:______Group Number: ______
Address to send Claims: ______
Phone Number:______
Fax Number: ______
Mental Health Information:
Briefly, why are you seeking treatment at this time? ______
Have you ever seen a psychotherapist before? If so, when and for what concerns? ______
If you have seen a therapist before, did you find it effective? ______
How would you describe your current state of mental health? ______
Have you ever been diagnosed with a mental illness? ______If so, what? ______
Has anyone in your family been diagnosed with a mental illness? If so, who and what illness? ______
Have you ever been hospitalized for a mental illness? If so, please give dates, hospitals and reason for admission:______
Are you currently taking any medications for mental health issues? If so,what?
______
If you are taking medications, who is prescribing them? ______
Phone number of prescribing physician: ______
If you do not currently take medications for mental health issues, have you ever done so in the past? If so, what have you taken? ______
Have you ever attempted suicide? ______If yes, please list dates, method(s) and age of occurrence: ______
Has anyone in your family attempted or completed suicide? ______If yes, who?______
Do you currently have difficulty sleeping? ______If yes, please describe: ______
Do you currently or have you ever had problems with eating or with food? ______If yes, please describe: ______
Medical Information:
Do you currently have any medical concerns or problems? If so, what? ______
Are you currently under the care of a medical doctor or other medical health professional? ____
Name of Primary Care Physician: ______Phone: ______
Name of Specialist Physician: ______Phone:______
Do you now have, or have you ever had in the past, any of the following? (Circle all that apply)
Victoria S. Young, LCSW-C
8 Reservoir Circle, Ste. 103
Baltimore, MD 21209
410-303-1927
Asthma
Brain Injury
Heart Disease
High Blood Pressure
Digestive Disorder
Fibromyalgia
Multiple Sclerosis
Tuberculosis
Victoria S. Young, LCSW-C
8 Reservoir Circle, Ste. 103
Baltimore, MD 21209
410-303-1927
Thyroid Disorder
Seizures
Epilepsy
Severe Headaches
Diabetes
Vision problems
Hearing problems
Cancer
Allergies
Sleep Disorder
Immune System Problems
Urinary Disorder
Liver Disease
Arthritis
Victoria S. Young, LCSW-C
8 Reservoir Circle, Ste. 103
Baltimore, MD 21209
410-303-1927
Please list any prescription medications you are taking:______
______
Please list any over the counter medications, herbal supplements or vitamins that you are currently taking:______
Please indicate substances currently used (over the past six months), how much at one time, how many times per day/week, age of first use, past use history and length of time used:
Substance / Current / Amount / Frequency / Age / Past / LengthCaffeine
Alcohol
Tobacco
Marijuana
Cocaine/Crack
Steroids
Ecstasy (MDMA)
PCP/LSD/Mushrooms
Pain Killers
Tranquilizers
Heroin
methamphetamines
Diet Pills
Have you ever felt your substance use was a problem for you? ______
Has anyone else in your life ever told you that they think your substance use is a problem? ______
Have you ever had problems with relationships, work, the law or your health as a result of substance use? If yes, please describe:______
______
Have you ever had withdrawal symptoms when trying to stop any substance? ______
Have you ever participated in drug/alcohol treatment? ______If so, when and what type of treatment?______
Spiritual Information:
Do you currently, or have you ever, engaged in a faith practice? ______If yes, please describe: ______
Are you currently a member of a faith community? ______If so, please describe your current level of involvement/connection:______
______
Relationship Information:
Are you currently in a relationship? ______If so, please list status: ______
How would you describe your sexual orientation? ______
Number of Marriages: ______
Number of Divorces: ______
If Widowed, your age at death of spouse: ______
Do you have children? If so, please provide names and ages ______
Do they currently live with you? ______Is there a custody arrangement? ______If they do not live with you, where do they live?______
Please list all people in your household and relationship to them: ______
Family Information:
Were you adopted? If so, at what age? ______
With whom did you live until the age of 18? ______
Is your mother living? ______If so, how old is she?______If not, when did she die?______
Is your father living?______If so, how old is he?______If not, when did he die?______
Do you have siblings? If so, please list names and ages: ______
Were you ever in foster or residential care?______If so, at what age(s)? ______
Have you ever experienced the death of a close family member or friend? (including but not limited to
parents)______
Have you ever experienced any of the following? (Circle all that apply)
Victoria S. Young, LCSW-C
8 Reservoir Circle, Ste. 103
Baltimore, MD 21209
410-303-1927
Emotional Abuse
Physical Abuse
Sexual Abuse
Domestic Violence
Neglect
Serious Illness
Accident or Injury
Legal problems
Homelessness
Financial Problems
Discrimination
Sexual Assault
Victoria S. Young, LCSW-C
8 Reservoir Circle, Ste. 103
Baltimore, MD 21209
410-303-1927
Educational/Vocational Information:
Please indicate your highest level of education (Circle one)
Elementary School
High School
College
Graduate School (Masters or PhD)
Technical School
Have you ever served in the Military? ______If so, please indicate your rank and current status: ______
As a member of the military, did you ever experience combat? ______
Current Employer: ______
Job Title/Description: ______
How long have you been at this job? ______
Have you ever had difficulty keeping jobs, or remaining at them? ______If so, please describe:______
Have you ever been fired from a job? ______If so, what for? ______
Please list your personal interests or hobbies: ______