ADULT – BACKGROUND & HISTORY

Who is your provider?*
Today’s date
MM slash DD slash YYYY
Client Legal Name
First Middle Last
Client Preferred Name
First Middle Last
Date of Birth
Month
Day
Year
Street Address
Street Address Address Line 2 City State ZIP Code
Preferred Email Address*
Would you like to subscribe to our newsletter?*
- Yes, keep me up to date with latest news and updates.
Client's Preferred Phone
Phone Type
- Cell
- Home
- Work
Gender Identity
Sex Assigned at Birth
Occupation
Employer or School (if student)
Marital status
Spouse/Partner (if applicable) and Occupation
Other family members and ages
(please note whether living in or outside of the home)
How did you learn about this practice
Prior Mental Health Care
First Mental Health Care
When?
Where?
Diagnosis (if applicable)?
Most Recent Care
When?
Where?
Diagnosis (if applicable)?
FINANCIALLY RESPONSIBLE PARTY
An adult client or an adult guardian who has assumed the cost of treatment. Payment is expected at the time of service.
Name
First Last
Relationship
Address
Street Address Address Line 2 City State ZIP Code
Emergency Contact
Relationship
Phone
PRESENTING PROBLEM(S)/ SYMPTOMS: (type and duration). How do these impact your functioning (at home, work, school, interpersonally)?
HISTORY OF DIFFICULTY AND PRECIPITATING FACTORS
PSYCHIATRIC TREATMENT HISTORY, MEDICATIONS
If none reported, check here
- None reported
PERTINENT BACKGROUND
(# of siblings, marriages/significant relationships, children, impacting events, e.g. moves, developmental changes, sexual/physical/emotional abuse, trauma, divorce.)
MEDICAL HISTORY
(Current & past medications & dosages, illnesses, etc.)
If none reported, check here
- None reported
SUBSTANCE USE AND ANY SUBSTANCE ABUSE HISTORY
(Client or Family)
If none reported, check here
- None reported
SOCIAL/SPIRITUAL/INTERPERSONAL SUPPORT SYSTEM OR ACTIVITIES
If none reported, check here
- None reported
LEGAL ACTIVITY
(Arrests, violations, warnings, Conditional Discharge, DWIs, probation (past or present), guardianships, durable power of attorney, living wills, JSOs, DCYF involvement, etc.)
If none reported, check here
- None reported
Abuse &/or Neglect
- Yes
- No
Delinquency
- Yes
- No
If Yes to any of the above, please list contact person
What are your strengths, or other things you are particularly good at or enjoy doing?
Medical Information
Present health of client
Previous medication (not for common illnesses)
Current medications (include all and who is prescribing them)
Have you been hospitalized or had surgeries (please describe)
Last Vision Test Date
Month
Day
Year
Do You Wear Glasses?
- Yes
- No
If Yes, When?
Month
Day
Year
Last Hearing Test Date
Month
Day
Year
Do You Use Hearing Aids?
- Yes
- No
Any family history of mental health concerns?
(i.e. Adhd, learning disabilities, depression alcoholism, anxiety) or neurological disorders (i.e. seizures, Tourettes, autism)
Prior Psychological Evaluations/Treatment
Have you been evaluated previously?
- Yes
- No
If yes, please indicate where this occurred, when and why the evaluation was conducted.
Are you currently receiving counseling or therapy services elsewhere?
- Yes
- No
If yes, please indicate name of provider and length of time being seen?
Other care professionals you are currently undergoing treatment with (e.g. other medical professionals such as acupuncturist, chiropractor, medical specialists, etc.)
Physician
Phone
Address
Street Address Address Line 2 City State ZIP Code
Other
Phone
Address
Street Address Address Line 2 City State ZIP Code
Other
Phone
Address
Street Address Address Line 2 City State ZIP Code
Other
Phone
Address
Street Address Address Line 2 City State ZIP Code
Any other information that you feel is important for me to know?
Name
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1245 Washington Road
Rye, New Hampshire 03870

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ADULT – BACKGROUND & HISTORY

Prior Mental Health Care

FINANCIALLY RESPONSIBLE PARTY

Medical Information

Prior Psychological Evaluations/Treatment