Couple – background & history - Insights Group Psychological Services

Email

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Who is your provider?*

Today’s date*

Preferred Email Address*

Client's Preferred Phone*

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*

Who?*

When?*

What is the main area of concern that led you to couples/family counseling now?*

How long have you and your partner been together? In what form? (ex: dating, engaged, married, etc).*

Does either partner partake in any form of substances?*

Who?*

What?*

How often?*

If yes, describe the frequency and catalysts?*

What are some examples of good qualities in your relationship?*

What are some examples of negative qualities in your relationship?*

What is your biggest goal for couples counseling?*

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.

Relationship*

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*

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.)

SUBSTANCE USE AND ANY SUBSTANCE ABUSE HISTORY*

(Client or Family)

SOCIAL/SPIRITUAL/INTERPERSONAL SUPPORT SYSTEM OR ACTIVITIES*

LEGAL ACTIVITY*

(Arrests, violations, warnings, Conditional Discharge, DWIs, probation (past or present), guardianships, durable power of attorney, living wills, JSOs, DCYF involvement, etc.)

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)*

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

If yes, please indicate where this occurred, when and why the evaluation was conducted.*

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*

Other

Phone

Other

Phone

Other

Phone

Any other information that you feel is important for me to know?