Proven Progress Counseling and Trauma Treatment, PLLC ...
Mental Health Personal Information FormName:____________________________________________ Today’s Date: _________________What leads you to seek counseling now? Please explain. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________Please describe any symptoms that are currently bothering you:____________________________________________________________________________________________________________________________________________________________________________________MEDICAL HISTORY/HEALTH PROBLEMS: (Check all those that apply)____High blood pressure, history of heart problems____ History of head injury, strokes, Parkinson's____Orthopedic (broken bones, back, shoulder, hip, knee)____Respiratory (emphysema, asthma)____Digestive system, including liver____Reproductive system____Skin disease____Kidney disease____Diabetes, thyroid____Hepatitis, HIV____Hearing impairment____Visual impairment____Chronic painDo you have any problems with sexual functioning?? If yes, please explain: ??[?? ] No?? [?? ]? Yes: __________________________________________________________________________________________Do you have any drug allergies? Please specify: ___________________________________________________What is the name of your Primary Healthcare provider? ____________________________________________ Have you had a medical exam within the last year? Yes NoWhat medications are you taking, including over-the-counter, herbals, vitamins: ____________________________________________________________________________________________________________________________________________________________________________________________________________FAMILY HEALTH HISTORY: Please comment on family members with major illnesses: ____________________________________________________________________________________________________________________________________________________________________________________ Has anybody in your family ever been diagnosed with or treated for a mental health problem? Please describe.____________________________________________________________________________________________________________________________________________________________________________________SLEEP ASSESSMENT: Estimated number of hours you sleep nightly __________Check all that apply:____ No difficulty____ Difficulty falling asleep____ Frequent awakenings____ Difficulty returning to sleep____ Tired on awakening____ Early morning awakenings____ Sleepwalking____ Snoring____ Sleep apnea____ Sleep too much____ Sleep during the day rather than at night____ NightmaresSOCIAL/DEVELOPMENTAL HISTORY:Where were you born and raised? ____________________________________________________________With whom did you grow up (parents, grandparents, foster home, etc.)? _____________________________Describe your relationship with your caregivers (parents, etc.): _____________________________________ ________________________________________________________________________________________How many brothers and sisters do you have? ___________________________________________________Was there any violence in your home? What kind? ______________________________________________________________________________________________________________________________________Were you abused as a child or adolescent? If so, check all that apply: Physical abuse Emotional abuse Sexual abuse NeglectMARITAL/RELATIONSHIP HISTORY:Marital Status: Single Married/ Domestic Partner/Common Law Divorced SeparatedLength of Current Relationship: ______________________________________________________________Sexual Orientation: ________________________________________________________________________Number of Children and their Ages: ___________________________________________________________Are there any problems in your current relationship? If so, please specify: ____________________________________________________________________________________________________________________ Verbal abuse, or sexual or physical violence may occur in some relationships. Is this a concern for you? Yes NoEDUCATION/VOCATIONAL EXPERIENCE:Highest level of education (list degrees): _______________________________________________________Specialized training or skills: _________________________________________________________________Current employment: ______________________________________________________________________If unemployed, date of most recent job and why you left: _________________________________________Did you have any difficulties in school? If so, please explain: _______________________________________________________________________________________________________________________________MILITARY HISTORY: If you did not serve in the military, please skip this section.Branch of service:__________________________ Dates of service:___________________________Dates of deployment:_______________________ Military occupation:________________________Highest rank:_____________________________ Type of discharge: _________________________LIVING SITUATION: Are there any problems in your current living situation? If so, please describe: ________________________________________________________________________________________________________________RELIGION/SPIRITUAL ORIENTATION: Do you have any religious/spiritual preferences? _______________________________________________Are there any spiritual or cultural factors that may be relevant to your treatment? Yes No If yes, please describe: _____________________________________________________________________FINANCIAL STATUS:Is your income adequate to meet your needs? Yes NoIs money a significant stress? Yes NoLEGAL HISTORY: Yes No Are you currently on probation or parole? For what offense? _________________________ Yes NoHave you ever been convicted of any criminal charge? If yes, please specify when and the charge(s): ________________________________________________________________ Yes No Do you have any pending charges? Please list: ______________________________________ __________________________________________________________________________Alcohol Use:? Yes NoDo you drink alcohol now? If yes, do you drink alcohol? daily weekly monthly? Yes NoHave you had any problems associated with your alcohol use? Yes NoHave you had a DUI? If yes, how many and when? _____________________________________ Yes NoAre you currently in recovery from drugs and/or alcohol? If so, If currently sober, what is your current time of sobriety? ___________________________________________What is your longest period of sobriety?______________________________________________________Drug Use:? Have you used any of the following within the past twelve months? Yes NoAmphetamines, ecstasy (meth, crystal, “X”…) Yes NoCannabis/Marijuana Yes NoCocaine Yes NoHallucinogens/psychedelics (LSD, acid, mushrooms…) Yes NoInhalants: gas, glue, paint thinner, etc. Yes NoOpioids (other than as prescribed) Yes NoOther (OTC, prescribed drugs, etc.) other than as directed Yes NoSpice, “bath salts” and/or other designer drugs Yes NoSteroidsOther Addictive Behaviors (gambling, overeating, sexual excess, internet):? Yes No If yes, Please describe:____________________________________________________________________Please describe any past use of alcohol, drugs and/or other addictive behaviors prior to the past 12 months:___________________________________________________________________________________Has anyone in your family had a drinking or a drug problem? Yes No Who: _______________________Do you use tobacco? Please check one: Lifetime Non-user of tobacco Former tobacco user but quit Current tobacco userMENTAL HEALTH HISTORY:Have you had any previous mental health counseling or treatment? Please specify when and where:____________________________________________________________________________________________________________________________________________________________________________________Have you ever been hospitalized for a mental health problem? Please specify when and where:____________________________________________________________________________________________________________________________________________________________________________________Have you ever been on mental health medications? (If so, please describe, including names, dosages & effects):____________________________________________________________________________________________________________________________________________________________________________________PERSONAL RISK: Yes NoHave you ever thought seriously of suicide? Yes NoHave you ever attempted suicide? If yes, please give details (when, why, how, what happened): ________________________________________________________________________________________________________________________________________ Yes NoDo you have a firearm or access to weapons? Please explain: _________________________________________________________________________________________________ Yes NoAre you feeling hopeless about the present or future? _______________________________________________________________________________________________________ Yes NoHave you had recent thoughts of hurting yourself? If yes when? How? Please describe:____________________________________________________________________________________________________________________________________________________ Yes NoDo you have a plan for suicide or self-harm? If yes what is your plan? ___________________________________________________________________________________________OTHER RISK: Yes NoHave you ever thought of killing or seriously injuring someone? Yes NoHave you ever attempted to kill or seriously injure someone? If yes, please give details (when, why, how, what happened): _____________________________________________________________________________________________________________________ Yes NoHave you had recent thoughts of killing or seriously injuring someone? If yes who? ________________________________________________________________PERSONAL STRENGTHS, NEEDS, ABILITIES & PREFERENCES:Strengths:What do you consider to be your personal strengths, assets and resources (for example: friendly, intelligent, healthy, have a place to live, supportive family/friends, etc.): _________________________________________________________________________________________________________________What do people like about you? _________________________________________________________________________________________________________________________________________________Needs:What are your needs or concerns at this time in your life? _____________________________________________________________________________________________________________________________What would you like to change in your life and what obstacles and limitations are getting in the way of what you want to achieve? ______________________________________________________________________________________________________________________________________________________Abilities:What are your personal talents, skills, and abilities? (What are you good at?) ____________________________________________________________________________________________________________PreferencesWhat preferences do you have that might improve your experience in treatment? ____________________________________________________________________________________________________________________________________________________________________________ What do you want to get from treatment / What are your treatment goals? ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Is there anything else that you feel we should know about you at this time, please write it here: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ................
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