Historical Information
Client’s name: _____________________________________
Date: _______________
Primary reason(s) for seeking services:
Anger management
Anxiety
Coping
Depression
Eating disorder
Fear/phobias
Mental confusion
Sexual concerns
Sleeping problems
Addictive behaviors
Alcohol/drugs
Other mental health concerns (specify):
Family Information
Living
Relationship
Name
Age
Yes
Living with you
No
Yes
No
Mother
Father
Spouse
Children
____
Significant others (e.g., brothers, sisters, grandparents, step-relatives, half-relatives. Please specify relationship.)
Living
Relationship
Name
Age
Yes
Living with you
No
Yes
No
Marital Status (more than one answer may apply)
Single
Divorce in process
Length of time:
Legally married
Length of time:
Widowed
Length of time:
Unmarried, living together
Length of time:
Separated
Divorced
Length of time:
Length of time:
Annulment
Length of time:
Total number of marriages: _____
Assessment of current relationship (if applicable):
Good
Fair
Poor
Comments: ___________________________________________________________________________
1
Parental Information
Parents legally married
Mother remarried: Number of times:
Parents are currently separated
Father remarried: Number of times:
Parents are divorced
Special circumstances (e.g., raised by person other than parents, information about spouse/children not living
with you, _______________________________________________________________________________
________________________________________________________________________
Development
Are there special, unusual, or traumatic circumstances that affected your development?
Yes
No
If yes, please describe:
Has there been history of child abuse?
Yes
If Yes, which type(s)?
Physical
Sexual
If yes, the abuse was as a:
Other childhood issues:
Victim
No
Verbal
Perpetrator
Neglect
Inadequate nutrition
Other (please specify):
Comments about childhood development:
Describe your relationship with your father:
____________________________________
________________________________________________________________________
Describe your relationship with your mother:
____________________________________
________________________________________________________________________
How would you describe your relationship with your brothers and/or sisters ?
____________________
________________________________________________________________________
________________________________________________________________________
Social Relationships
Check how you generally get along with other people: (check all that apply)
Affectionate
Friendly
Other (specify):
Aggressive
Leader
Sexual orientation:
Sexual dysfunctions?
Avoidant
Outgoing
Comments:
_____Yes
____ No
If yes, describe:
2
Fight/argue often
Shy/withdrawn
Follower
____ Submissive
Cultural/Ethnic
To which cultural or ethnic group do you belong?
Have you experienced any problems due to cultural or ethnic issues (past or present)?
____ Yes ____ No If yes describe: ___________________________________________________
___________________________________________________________________________________
Spiritual/Religious
How important to you are spiritual matters?
Not
Little
Are you affiliated with a spiritual or religious group?
Yes
Moderate
Much
No
If yes, describe:
Were you raised within a spiritual or religious group?
Yes
No
If yes, describe:
Would you like your spiritual/religious beliefs incorporated into the counseling?
Yes
No
If yes, describe:
Legal
Current Status
Are you involved in any active cases (traffic, civil, criminal)?
Yes
No
If yes, please describe and indicate the court and hearing/trial dates and charges:
Are you presently on probation or parole?
Yes
No
If yes, please describe:
Past History
Traffic violations:
Yes
No
DWI, DUI, etc.:
Yes
No
Criminal involvement:
Yes
No
Civil involvement:
Yes
No
If you responded Yes to any of the above, please fill in the following information.
Charges
Date
Where (city)
Results
Education
Fill in all that apply:
Years of education:
Currently enrolled in school?
High school grad/GED
Vocational:
Number of years:
Graduated:
Yes
No Major:
College:
Number of years:
Graduated:
Yes
No Major:
Graduate:
Number of years:
Graduated:
Yes
No Major:
Other training:
Special circumstances (e.g., learning disabilities, gifted):
3
Yes
No
Employment
Begin with most recent job, list job history:
Employer
Dates
Currently:
FT
Title
PT
Temp
____Student
Social Security
Reason left the job
Laid-off
How often missed?
Disabled
Retired
_____Other (describe):__________________
Military
Military experience?
Yes
No
Combat experience?
Yes
No
Where:
Branch:
Discharge date:
Date drafted:
Type of discharge:
Date enlisted:
Rank at discharge:
Leisure/Recreational
Describe special areas of interest or hobbies (e.g., art, books, crafts, physical fitness, sports, outdoor
activities, church activities, walking, exercising, diet/health, hunting, fishing, bowling, traveling, etc.)
Activity
How often now?
How often in the past?
Nutrition
Describe your eating habits (typical foods, typical amounts, how often ):______________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
_______________________________________________________________________
4
Medical/Physical Health
AIDS
Alcoholism
Abdominal pain
Abortion
Allergies
Anemia
Appendicitis
Arthritis
Asthma
Bronchitis
Bed wetting
Cancer
Chest pain
Chronic pain
Colds/Coughs
Constipation
Chicken Pox
Dental problems
Diabetes
Diarrhea
Dizziness
Drug abuse
Epilepsy
Ear infections
Eating problems
Fainting
Fatigue
Frequent urination
Headaches
Hearing problems
Hepatitis
High blood pressure
Kidney problems
Measles
Mononucleosis
Mumps
Menstrual pain
Miscarriages
Neurological disorders
Nausea
Nose bleeds
Pneumonia
Rheumatic Fever
Sexually transmitted diseases
Sleeping disorders
Sore throat
Scarlet Fever
Sinusitis
Smallpox
Stroke
Sexual problems
Tonsillitis
Tuberculosis
Toothache
Thyroid problems
Vision problems
Vomiting
Whooping cough
Other (describe):
List any current health concerns: _________________________________________________________
List any recent health or physical changes __________________________________________________
_____________________________________________________________________________________
Current prescribed medications
Dose
Dates
Purpose
Side effects
Current over-the-counter meds
Dose
Dates
Purpose
Side effects
Date
Reason
Results
Last physical exam
Most recent surgery
Other surgery
Upcoming surgery
Family history of medical problems: ________________________________________________________
______________________________________________________________________________________
5
Please check if there have been any recent changes in the following:
Sleep patterns
Eating patterns
Behavior
Energy level
Physical activity level
General disposition
Weight
Nervousness/tension
Describe changes in areas in which you checked above:
Chemical Use History
Substance use
Method of
Frequency Age of Age of
use and amount
of use
first use last use
Used in last Used in last
48 hours
30 days
Yes
No
Yes
No
Alcohol
Marijuana
Other drugs:
_______________
_______________
Caffeine
Nicotine
Substance of preference
1.
2.
Substance Abuse Questions
Describe when and where you typically use substances:
Describe any changes in your use patterns:
Describe how your use has affected your family or friends (include their perceptions of your use):
Reason(s) for use:
Addicted
Build confidence
Escape
Socialization
Taste
Other (specify):
Self-medication
How do you believe your substance use affects your life?
Who or what has helped you in stopping or limiting your use?
Does anyone in your family present/past have/had a problem with drugs or alcohol?
Yes
No
If Yes, describe:
Have you had withdrawal symptoms when trying to stop using drugs or alcohol?
If yes, describe:
6
Yes
No
Have you had adverse reactions or overdose to drugs or alcohol? (Describe):
Does your body temperature change when you drink?
Yes
No
Yes
No
If yes, describe:
Have drugs or alcohol created a problem for your job?
If yes, describe:
Counseling/Prior Treatment History
Information about client (past and present):
Yes
No
When
Counseling
Psychiatric treatment
____ ____
Suicidal thoughts/attempts
Drug/alcohol treatment
Hospitalizations
Involvement with self-help
groups (e.g., AA, Al-Anon,
NA, Overeaters Anonymous)
Where
Your reaction
to overall experience
_________________ __________________
____________ _________________ __________________
__________________
__________________
__________________
__________________
Describe any past or present treatment information pertaining to family/significant others (past and
present):
_____________________________________________________________________________________
_____________________________________________________________________________________
Please check behaviors and symptoms that occur to you more often than you would like them to
take place:
Aggression
Alcohol dependence
Anger
Antisocial behavior
Anxiety
Avoiding people
Chest pain
Cyber addiction
Depression
Disorientation
Distractibility
Dizziness
Drug dependence
Eating disorder
Elevated mood
Fatigue
Gambling
Hallucinations
Heart palpitations
High blood pressure
Hopelessness
Impulsivity
Irritability
Judgment errors
Loneliness
Memory impairment
Mood shifts
Panic attacks
Phobias/fears
Recurring thoughts
Sexual addiction
Sexual difficulties
Sick often
Sleeping problems
Speech problems
Suicidal thoughts
Thoughts disorganized
Trembling
Withdrawing
Worrying
Other (specify):
Briefly discuss how the above symptoms impair your ability to function effectively:
7
Please answer the following questions with YES or NO:
YES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14
15.
16.
I feel that people expect more from me than I can give.
I feel that my living and/or working situations are more of a problem than my drinking
and/or drug use.
I feel helpless; i.e., unable to change my situation myself.
I feel ashamed and/or guilty regarding my recent behavior/ actions.
I am angry with myself.
I am angry with others.
I feel more alone recently.
I do not trust others as much as I used to.
I feel that life is worth living.
Have you always been able to stop drinking or using drugs when you wanted to?
Has your functioning and/or performance deteriorated recently in work, home or school?
Do you communicate freely with others?
Do you prefer to avoid discussing how you feel?
Have arguments or conflicts with others increased recently?
Have friends or loved ones told you that your behavior worries them?
Do you have difficulty sleeping or has your sleeping pattern changed?
What are your goals for therapy?
Do you feel suicidal at this time?
Yes
No
If yes, explain:
Any additional information that would assist us in understanding your concerns or problems:
For Staff Use
Therapist’s signature/credentials:
Date:
/
/
_
_
__________________________________________
________________________________________________________________________
__________________
Comments:
8
NO