Amy M. Jones, MA, LPC-S
Individual and Group Counselor
718 W. Arapaho, Ste. 100
Richardson, Texas 75080
214-755-3712
CONFIDENTIAL QUESTIONNAIRE - ADULT
Client Contact Information
Client Name:
_______________________________________________________
Address:
_______________________________________________________
City/State/Zip:
_______________________________________________________
Ok to send mail to this address? Yes No
Primary Phone:
_______________________________________________________
Ok to leave message at this number? Yes No
Secondary Phone:
_______________________________________________________
Ok to leave message at this number? Yes No
Email:
_______________________________________________________
Ok to leave message via email? Yes No
Social Security Number (last 4 digits):___________________________________________________
Date of Birth:
_______________________________________________________
Emergency Contact:
_______________________________________________________
Relationship:
_______________________________________________________
Phone:
_______________________________________________________
Who referred you to this office? _______________________________________________________
May I contact them to thank them for the referral? ____Yes ____No
Chief Complaint
Problems(s) and symptoms for which you are seeking counseling?
When did you begin experiencing these problems/symptoms?
How frequently do you experience these problems/symptoms?
On a scale of 1 to 10 (1 being least severe, 10 is most severe), where do you rate your presenting problems at this time?
1
What prompted you to seek counseling now?
Previous Treatment
List all previous counseling or psychological treatment you have received in the past:
(Include hospitalizations for psychiatric reasons)
Date
Problem
Provider
Results/Reason for Ending Treatment
List any mental health diagnosis, date of diagnosis and name of diagnosing physician:
Medical History
How would you rate your present physical health? (circle one) Excellent Good Poor
When was your last physical exam?
Findings from that exam and lab results?
Current medications (Prescriptions and Over-the-Counter):
Name
Dosage
Medical Conditions
Frequency
Date Began
Date Diagnosed
Prescribing Physician
Treating Physician
Allergies:
Adverse reactions or sensitivities to foods, drugs or other substances:
2
Symptoms (circle all that apply)
Sleep Disturbance
Poor Concentration
Appetite Disturbance
Crying Spells
Low Energy
Depressed Mood
Mood Swings
Irritability
Anxiety
Panic Attacks
Phobias
Sexual Problems
Paranoid Thoughts
Hallucinations
Delusions
Aggressive Behavior
Oppositional Behaviors
Obsessions/Compulsions
Anorexia
Bingeing/Purging
Thoughts of Self-harm
Attempted Suicide
Thoughts of Harm to Others
Others __________________________________________
Family History
(Please indicate if deceased and date of death)
Number and Age(s) of Children
Number and Age(s) of Siblings
Age of Parents
Is there a family history (grandparents, parents, siblings, children) of mental health conditions or substance abuse?
If yes, please describe:
Social History
Current Marital Status (Circle One)
Single Engage Married Domestic Partner
Divorced Separated Widowed
Previous Marriages (number, length marriage):
Education Completed (grade or degree):
Mental health/psychology coursework:
Occupation (type, employer, # years at current job):
Military Service (Branch, Rank, # of years):
Spiritual/Religious Preference:
Any current legal issues?
Have you ever filed a complaint against a professional? If yes, please explain:
Any other information that could help the therapist not otherwise included here:
____________________________________________
Client Signature
___________________________
Date
___________________________________________
Printed Name
3