Carol L. Clark, Ph.d., lmhc, cap

www.drcarolclark.com      Contact Me

   

 

Name:              

Date:               (MM/DD/YYYY)

Telephone #              

e-mail:              

Address:  

Date of Birth:               (MM/DD/YYYY)

Emergency Contact Name and relationship:              

telephone number:              

 

Intake and History

 

Please answer all of the following questions as fully as possible.  Your answers are completely confidential except as required by law (please review the hipaa notice of privacy practices)  The purpose of this questionnaire is so I can treat you as effectively and expeditiously as possible.

 

Introductory Questions

 

1. How did you find me?

 

2. Please describe your situation in one sentence. What is the problem in your own words?

 

2a. How do you see the Situation?

(Chief Complaint, presenting problem, needs; Symptoms, frequency, duration, intensity, latency, recurrence, course; Distress caused, change efforts; Precipitants, consequences, context, relevant history)

 

 

 

The History

 

3. Previous psychological episodes, treatment providers and treatments:

 

4. Current psychological concerns, treatment, medications:

 

5. Personal or family related help/counseling/ therapy:

When:

# sessions:

With whom/credentials

Problems you consulted them for

Type of therapy received

Satisfaction with, difficulties, outcomes.

 

6. Hospitalizations/home rest for “nervous breakdowns”/suicide attempts/social agency contacts:

 

7. Education History:

           High School:

           College:

           Technical School:

 

8. Work History

            Name of employer:

            Job title:

            Salary:

How long:

            Why left:

            Repeat for last five jobs

 

9. Alcohol and other drug use

            What drug:

            How much used:

            How often:

            Have you tried to cut down or quit:        When:

            Any treatment:

Repeat for alcohol and each drug used.

 

 

10. History of Abuse: verbal, physical, sexual, marital, elder, childhood, family of origin, level of violence.

 

11. Legal History/Trouble with the law/police

# of arrests

Charges:

Convictions:

Sentences?

 

            Litigation anticipated, pending or in past, especially

            against therapists. Lawyer’s name/#:

 

12. Health:

           Major current and historical health problems:

When:

How treated:

By whom:

Allergies?      

 

            All current medications: (over the counter, prescription, daily and rarely)

Name of medication

Dosage:

How often:

What for:

 

            Date of last exam by an MD:

   

13. Family of Origin:

Where were you raised:

Who raised you:

# of brothers and sisters and their ages:

Any domestic violence:

Any alcohol or substance abuse:

 

Please say a little about each of the following, regarding your family while growing up:

affection,

control,

discipline,

expectations,

aspirations,

personalities,

mental health,

abuse,

religion,

schooling,

occupations,

marriages,

legal.

Important friendships:

 

14. Health of family members:

Chronic illnesses,

Deaths:

Parent’s/relatives health - especially similar (to your) problems.

 

15. Current marriage/family situation

How met:

Type of relationship:

How long:

Changes:

Stressors:

Domestic violence:

Alcohol or substance abuse:

 

# and ages of children, problems or concerns.

 

16. Anything I haven’t asked about that is relevant/important/I should know?

 

17. Have you thought about hurting yourself any time in the past 30 days?  Describe:

 

18. Have you thought about hurting anyone else in the past 30 days?  Describe:

 

19. Eating patterns, exercise, sleep?

            How often:

            How well:

            Any concerns:

 

20. Ambitions? Goals? Work satisfaction?  Please say a little about each.

 

21. What do you hope therapy will do?/Outcome(s) of treatment? (expectations, harmony of)

 

22 a. What do you want to change about yourself? Aspects of your life (strengths, resources, abilities, supports, education, employment, feelings, behaviors,

      developmental stage, relationships.)

   

    b. How important do you feel these changes are? (Rank these changes by importance.)

    

     c. How long do you think these changes will take?

    

 

23. How does therapy work? What do you think a therapist should be like?

 

24. Major crises of last 1-5 years and how you handled them:

 

25. When are you happy?

 

26. What persons, ideas or forces have been most useful/influential to you in the past?

 

27. Current positives in life? (Hobbies? Sports? Family? Security?)   

 

28. Spiritual or religious issues? Existential concerns? Influence of culture?