October 7, 2020by grebouskipsych@gmail.com ADULT – CLINICAL SUMMARY Who is your therapist?*Dr. Robin BuckleyDr. Tom GrebouskiDr. Sharyn DrewElian M. Beattie, M.S., LMHCJonathan R. Stearns, M.Ed.Today’s date Date Format: MM slash DD slash YYYY Patient Name First Middle Last Date of Birth MM DD YYYY Street Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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. Patient's Preferred PhonePhone TypeCellHomeWorkGenderMaleFemaleOtherOccupationEmployer or School (if student)Marital statusSpouse/Partner (if applicable) and OccupationOther family members and ages(please note whether living in or outside of the home)How did you learn about this practicePrior Mental Health CareFirst Mental Health CareWhen?Where?Diagnosis (if applicable)?Most Recent CareWhen?Where?Diagnosis (if applicable)?FINANCIALLY RESPONSIBLE PARTYAn adult client or an adult guardian who has assumed the cost of treatment. Payment is expected at the time of service.Name First Last RelationshipAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency ContactRelationshipPhonePRESENTING PROBLEM(S)/ SYMPTOMS: (type and duration). How do these impact your functioning (at home, work, school, interpersonally)?HISTORY OF DIFFICULTY AND PRECIPITATING FACTORSPSYCHIATRIC TREATMENT HISTORY, MEDICATIONSIf 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(Patient or Family)If none reported, check here None reported SOCIAL/SPIRITUAL/INTERPERSONAL SUPPORT SYSTEM OR ACTIVITIESIf 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 NeglectYesNoDelinquencyYesNoIf Yes to any of the above, please list contact personWhat are your strengths, or other things you are particularly good at or enjoy doing?Medical InformationPresent health of patientExcellentGoodNormalFairPoorPrevious 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 MM DD YYYY Do You Wear Glasses?YesNoIf Yes, When? MM DD YYYY Last Hearing Test Date MM DD YYYY Do You Use Hearing Aids?YesNoAny 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/TreatmentHave you been evaluated previously?YesNoIf yes, please indicate where this occurred, when and why the evaluation was conducted.Are you currently receiving counseling or therapy services elsewhere?YesNoIf 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.)PhysicianPhoneAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code OtherPhoneAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code OtherPhoneAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code OtherPhoneAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Any other information that you feel is important for me to know?EmailThis field is for validation purposes and should be left unchanged.
