October 7, 2020by [email protected] ADULT – BACKGROUND & HISTORY "*" indicates required fields Who is your provider?*Dr. Tom GrebouskiDr. Laura ObertElian M. Beattie, M.S., LMHCSuerae Stein, M.A., LMHCMatthew Garthwait, M.S.W., LICSWSheri Flaherty, M.S.W., LICSWCecelia Tarr, M.S.W., LICSWAdrienne Dwyer M.A.Dr. Sharyn DrewLaura Trachtenberg, M.A.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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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. Client's Preferred Phone*Phone Type* Cell Home Work Gender Identity*MaleFemaleNon-binaryTransmasculineTransfeminineSomething not listed aboveSex Assigned at Birth*MaleFemaleOtherOccupation*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 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 Relationship*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 InformationPresent health of client*ExcellentGoodNormalFairPoorPrevious 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/TreatmentHave 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.)PhysicianPhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code OtherPhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code OtherPhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code OtherPhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Any other information that you feel is important for me to know?NameThis field is for validation purposes and should be left unchanged. 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