Victoria S. Young, LCSW-C

Victoria S. Young, LCSW-C

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 / Length
Caffeine
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: ______