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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Elian Beattie
Dr. Tom Grebouski
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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