Foundations
Counseling & Consultation Services, LLC
Adult Information Form
Date: _______________
Personal Information
Name: _______________________________________________ DOB: ______________ Age: ______
Sex: M F (circle)
Home Phone: ______________________ Cell Phone: ______________________
Address: _____________________________________________________________________________
Marital Status: ______________________ Spouse/Partner Name: ______________________________
Employer: _______________________________ Occupation: _________________________________
Please Circle the Following Symptoms/Concerns:
Anger
Depressed Mood
Nervousness
Recent Loss (loved one, job, etc.)
Impulsivity
Low Self Esteem
Stress
Relationship Problems
Health Concerns
Memory Loss/Forgetful
Restless
Racing Thoughts
Lack of Motivation
Mood Swings
Irritable
Difficulty Making Decisions
Sad Mood
Recent Move
Increased Sleep
Increased Appetite
Excessive Worry
Decreased Sleep
Decreased Appetite
Nightmares
Difficulty at Work
Difficulty w/Organization
Auditory Hallucinations
Easily Distracted
Unable to Concentrate
Fatigue
Pressured Speech
Exposure to Traumatic Event
Excessive Fears
Difficulty Concentrating
Visual Hallucinations
Illness
Family Conflict
Feelings of Worthlessness
Hopeless
Decrease Interest in Activities
Panic Attacks
Feeling Anxious
Fearful of Being Alone
Avoids Social Interactions
Loses Temper
Substance Use
Decreased Energy
Domestic Violence
Suicidal Thoughts/Attempt
Sexual Abuse
Self- Harm Behaviors
Foundations
Counseling & Consultation Services, LLC
Do you have any Physical Concerns? _______________________________________________________
_____________________________________________________________________________________
Do you have any Eating Behavior Concerns (Binging, Vomiting, Restricted Eating, Excessive Dieting)?
_____________________________________________________________________________________
_____________________________________________________________________________________
Reasons For Seeking Counseling
Please provide a brief description of your concerns:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
What are your goals for counseling?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Counseling/Addictions History
Have you sought counseling previously? YES
NO (circle)
If yes, dates of service(s): _______________________________________________________________
Where did you receive those services: _____________________________________________________
Have you ever been hospitalized for mental health issues? YES
NO (circle)
If yes, dates and reasons for hospitalization(s):
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Have you sought addictions treatment previously? YES
NO (circle)
If yes, dates of service(s): _______________________________________________________________
Where did you receive those services: _____________________________________________________
_____________________________________________________________________________________
Outcome of services: ___________________________________________________________________
Foundations
Counseling & Consultation Services, LLC
Family history of addictions: _____________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Medical Information
Primary Care Physician: ___________________________________ Phone: ______________________
Address: _____________________________________________________________________________
Current Medications: ___________________________________________________________________
Date of Last Physical Exam: ______________________________________________________________
Do you have any medical concerns? _______________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Significant medical history (illnesses, accidents, etc.):
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Additional Information
Please add any additional information that would be helpful to serve your needs to the best of my
ability:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Emergency Contact Information
Name: ___________________________________________ Phone: ____________________________
Name: ___________________________________________ Phone: ____________________________
