OASIS COUNSELING CENTER
SUPPORTING CLIENT DATA
Family Information
Family Configuration
Code Placements (1) Parent (2) Caretaker
1. With Whom Does Client Reside:
2. For How Long:
_____ 0 – 2 years
_____ 2-5 years
_____ 5 + years
_____ Unknown
_____ Biological Mother
_____ Biological Mother, Biological Father
_____ Biological Mother, Stepfather
_____ Biological Father
_____ Biological Father, Stepmother
_____Aunt
_____Uncle
_____ Grandparent
_____ Legal Guardian (Specify: ___________________________________ )
_____ Other (Specify: ___________________________________________)
3. Parents:
a. Mother
_____ Living
_____Deceased
b. Father
______ Living
______ Deceased
4. Parents Incarceration:
a. Mother
b. Father
_____ Y/N
______ Y/N
_____ Currently
______Currently
5. Biological Parental /Guardian Marital Status (Code them with 1 = Biological Parent; 2 = Guardian)
_____ Married
_____ Living Together
_____ Divorced
_____ Never Married
_____ Separated
_____ Unknown
6. Number of Siblings: _____None _____1 _____2 _____3 _____4 _____ 5 _____ 6+_____ Unknown
7. Number in Birth Order_____ Number in Birth Order Unknown_____
8. Current Sibling Incarceration:
_____ Yes
_____ No
_____ Unknown
If yes, # _______
9. Siblings Previously Incarcerated:
_____ 1 _____ 2 _____ 3+ _____ None _____ Unknown
10.
Do you get along with your family and friends? Yes ____ No ______
11. Are you close with anyone in your family? Yes ___No ___ Who? _____________________________
12. Do your parents/caretakers have any problem with? (Code them with 1 = Biological Parent; 2 =
Caretaker)
___involvement with legal system ___mental health
___health
___finding/keeping job
___marital discord
___alcohol/drug abuse
___other_________________
___none
___does not apply
13. How are the members of your household disciplined?
___no discipline
___verbal punishment
___physical punishment
___ loss of privileges
Reported By:_________________________
___ restriction
___ other
___time outs
14. Who administers the discipline in the home? _______________________________________________
15. Have you ever been physically abused?
_____Y ______N
16. What happened? _____________________________________________________________________
17. How often did it occur? _______________________________________________________________
18. When was the last time? ______________________________________________________________
19. Has it been reported? _____ Unknown
_____Y _____N
20. Did you receive treatment? ______Y ______N If yes, explain: _______________________________
21. Have you ever been touched in a way you did not like?
Yes ___ No ___ If yes, explain _____________________________________________________
22. Have you ever been forced or pressured into having sex by anyone?
Yes ___ No ___ If yes, by whom and when? ___________________________________________
_______________________________________________________________________________
Has it been reported? Yes ___ No ___
23. Have you ever been accused of touching someone inappropriately?
Yes ___ No ___ If yes, whom and when? _____________________________________________
24. Have you ever seriously considered calling the police because of the way members of your household
were acting?
Yes ___ No ___If yes, explain ______________________________________________________
25. Are there any personal safety concerns in the home and/or community?
Yes ___ No ___If yes, explain ______________________________________________________
26. Are there any current, prior, or pending CPS complaints?
Yes ___ No ___If yes, explain ______________________________________________________
EDUCATION INFORMATION
27. What are your goals concerning school?
___graduation
___drop out
___GED
___technical school
___junior college
___graduate/professional
___college
HEALTH/MEDICAL INFORMATION
28. Are you sexually active? ______Y ______N If yes, how many partners have you had? _________
Do you use protection? ______Y ______N
Have you ever had an STD? _______Y ______N If yes, what?_______________________________
Do you receive regularly scheduled examinations? ______Y ______N
29. Have you ever been pregnant? ____Y
Do you have any children of your own?
Do you have financial support? _____Y
Do you have any involvement? _____Y
_____N
_____N/A
____Y _____N How many? ______
_____N
____N Describe: ________________________________
30. Major Illnesses/Conditions:
_____ Y _____ N_____ Unknown
If yes, specify: ___________________________________
31. Brain Injury
_____ Y _____ N _____ Unknown
If yes, specify: ___________________________________
32. Presently on Psychoactive and General Medication:
_____Y _____N ____ Unknown
If yes, specify: ___________________________________
33. Psychotropic Medications _____ Y
_____ N
If yes, what medications: Check all that apply.
4 = CARETAKER
_____ Unknown type
CODE 1 = CLIENT, 2 = MOTHER, 3 = FATHER,
** NOTE: brand names many be different than chemical names
** NOTE: many of these medications may be used for different categories
A. Antipsychotic
Haldol
Prolixin
Trilafon
Mellaril
Thorazaine
Navane
Loxitane
Stelazine
Zyprexa
Risperdal
Seroquel
Geodon
Clozaril
Dosage
Frequency
B. Antidepressant
Prozac
Paxil
Zoloft
Luvox
Celexa
Wellburtrin
Remeron
Serzone
Trazadone
Elevil
Pamelor
Tofranil
Triavil
Anafranil
Dosage
Frequency
C. Antianxiety
Xanax
Valium
Atavan
Tranxene
Buspar
Klonopin
Dosage
Frequency
E. Psychostimulants Dosage
Ritalin
Ritalin-SR
Cylert
Dexedrine
Adderall
Concerta
Metadate
Frequency
D. Anticonvulsants
Tegratol
Lithium
Depakote
Lamictal
Neurotin
Topromax
F. Other (Specify)
Dosage
Dosage
Frequency
Frequency
Mental Health /Substance Use Information
34. What is the most violent thing you have ever done?
__________________________________
________________________________________________________________________
35. What did you do the last time you got angry? _______________________________________
________________________________________________________________________
________________________________________________________________________
36. What happens when people tell you what to do? ___________________________________________
37. Are you in a gang? ____ Yes
____ No ____ Not disclosed
If yes, which one? ________________________________________________________________
38. Is there anything about yourself that you would like to change? Yes ___ No ___
If yes, Please explain: _____________________________________________________________
39. What do you like about yourself? _______________________________________________________
40. What do you think it will be like to work with an in-home counselor?
______________________
________________________________________________________________________
41. What do you think you can do to work successfully with your in-home counselor? ______________
________________________________________________________________________
Family History of Substance
42. Family History of Alcohol/drug Use: _____Y
_____N _____ Unknown _____ Not disclosed
If yes, which relative(s)? __________________________________________________________________
43. Specify Substance(s) by relative: C = Current
Mother
Alcohol
_____
Cocaine
_____
Marijuana
_____
Hallucinogens (LSD, PCP)
_____
Amphetamines (speed, crank)
_____
Methamphetamine (crystal meth) _____
Other (Specify)_____________
_____
P = Past
Father
____
____
____
____
____
____
____
U = Unknown
N = Not disclosed
Other Relative (specify)_________
_____
_____
_____
_____
_____
_____
_____
SIGNIFICANT LIFE EVENTS
Delinquent Behavior
44. Current Charges?: _______ Y __________N
If yes, Please explain: _____________________________________________________________
45. Previous Charges?:
_______ Y ________ N
If yes, Please explain: _____________________________________________________________
46. Conviction/Disposition: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Probation Officer: ____________________
47. History of suicide in family:
____ Y
____ N
Parole Officer: ______________________________
____Unknown
____ Not disclosed
48. If yes, who?
____ Mother, Method used: ________________
____ Father, Method used: __________________
____ Sister, Method used: _________________
____ Brother, Method used: _________________
____ Cousin, Method used: ________________
____ Grandmother, Method used: ____________
____ Grandfather, Method used: __________________
49. History of Friends Committing Suicide:____ Y
____ N ____ Unknown
____ Not disclosed
If yes, who? __________________________ Method Used: ____________________________
Victimization History
50. Experienced victimization
____ Y ____ N
____ No information known
____ No information disclosed
____ Youth denied abuse, but this information incongruent with record
____ Unable to recall
51. Multiple victimizations:
_____ Y _____ N
COLLECT INFORMATION ON THE FOLLOWING FORMS OF VICTIMIZATION – SEXUAL,
PHYSICAL, VERBAL, EMOTIONAL, NEGLECT.
52. Sexual
____ Yes
____ No
____ Not disclosed
53. Gender of Perpetrator:
_____ M
_____ F
_____ Male and Female
54. Age of Perpetrator:
_____ 0 – 12 yrs
_____ 13 – 18 years
_____ 19 – 25 years
_____ 26+ yrs
_____ Unknown
_____ Not disclosed
55. Frequency:
_____ 0 – 2 years
_____ 2 – 4 years
_____ 4 – 6 years
_____ 6+ years
_____ Unknown
_____ Not disclosed
56. Relationship of Perpetrator:
_____ Mother
_____ Friend
_____ Father
_____ Neighbor
_____ Sibling
_____ Other
_____ Uncle
_____ Unknown
_____ Aunt
_____ Not disclosed
_____ Childcare Provider
57. Acts Perpetrated:
_____ Digital Penetration
_____ Intercourse
_____ Oral
_____ Anal
58. Coercion: ____Y ____N Specify:_____________
_____ Exposure
_____ Voyeurism
59. How Disclosed Abuse:
_____ Other
______Participant Told
_____ Unknown
______Perpetrator Told
_____ Not disclosed
_____Witnessed by other
60. Physical
____ Yes
____ No
____ Not disclosed
61. Gender of Perpetrator:
_____ M
_____ F
_____ Male and Female
63. Frequency:
_____ 0 – 2 years
_____ 2 – 4 years
_____ 4 – 6 years
_____ 6+ years
_____ Unknown
_____ Not disclosed
64. Relationship of Perpetrator:
_____ Mother
_____ Friend
_____ Father
_____ Neighbor
_____ Sibling
_____ Other
_____ Uncle
_____ Unknown
_____ Aunt
_____ Not disclosed
_____ Childcare Provider
65. Coercion:
62. Age of Perpetrator:
_____ 0 – 12 years
_____ 13 – 18 years
_____ 19 – 25 years
_____ 26+ years
_____ Unknown
_____ Not disclosed
66. How Disclosed Abuse:
_____ Y
____Participant Told
_____ N
____Witnessed by Other If yes, Specify: ___________
_____ Perpetrator Told
67. Verbal
____ Yes
____ No
____ Not disclosed
68. Gender of Perpetrator:
_____ M
_____ F
_____ Male and Female
69. Age of Perpetrator:
_____ 0 – 12 years
_____ 13 – 18 years
_____ 19 – 25 years
70. Frequency:
_____ 0 – 2 years
_____ 2 – 4 years
_____ 4 – 6 years
_____ 6+ years
_____ Unknown
_____ Not disclosed
71. Relationship of Perpetrator:
_____ Mother
_____ Friend
_____ Father
_____ Neighbor
_____ Sibling
_____ Other
_____ Uncle
_____ Unknown
_____ Aunt
_____ Not disclosed
_____ Childcare Provider
_____ 26+ years
_____ Unknown
_____ Not disclosed
72. How Disclosed Abuse:
_____ Participant Told
_____ Witnessed by Other
_____ Perpetrator Told
_____ Other: ____________________
73. Emotional
____ Yes
____ No
____ Not disclosed
74. Gender of Perpetrator:
_____ M
_____ F
_____ Male and Female
75. Age of Perpetrator:
_____ 0 – 12 years
_____ 13 – 18 years
_____ 19 – 25 years
76. Frequency:
_____ 0 – 2 years
_____ 2 – 4 years
_____ 4 – 6 years
_____ 6+ years
_____ Unknown
_____ Not disclosed
77. Relationship of Perpetrator:
_____ Mother
_____ Friend
_____ Father
_____ Neighbor
_____ Sibling
_____ Other
_____ Uncle
_____ Unknown
_____ Aunt
_____ Not disclosed
_____ Childcare Provider
_____ 26+ years
_____ Unknown
_____ Not disclosed
78. How Disclosed Abuse:
_____ Participant Told
_____ Witnessed by Other
_____ Perpetrator Told
79. Neglect
____ Yes
____ No
____ Not disclosed
80. Gender of Perpetrator:
_____ M
_____ F
_____ Male and Female
81. Age of Perpetrator:
_____ 0 – 12 years
_____ 13 – 18 years
_____ 19 – 25 years
82. Frequency:
_____ 0 – 2 years
_____ 2 – 4 years
_____ 4 – 6 years
_____ 6+ years
_____ Unknown
_____ Not disclosed
83. Relationship of Perpetrator:
_____ Mother
_____ Friend
_____ Father
_____ Neighbor
_____ Sibling
_____ Other
_____ Uncle
_____ Unknown
_____ Aunt
_____ Not disclosed
_____ Childcare Provider
_____ 26+ years
_____ Unknown
_____ Not disclosed
84. How Disclosed Abuse:
_____ Participant Told
_____ Witnessed by Other
_____ Perpetrator Told
Religious/Spiritual Status
85. What is your religious affiliation?
___Baptist
___Catholic
___Non-Denominational
___Methodist
___Jewish
___Islamic
___Pentecostal
___Lutheran
___Jehovah Witness
___Mormon
___Seven Day Adventist
___Atheist
___Wicca
___Satanic
___None
___Other (Please Specify)_________________________________________________________________
86. Do you participate in worship services? ___Yes ___No
How often?
___Once a week
___ Twice a month
___+1 a Week
___Once a year
___Once a month
___Other (Specify)
What type of worship services do you participate in? ____Congregational Worship
___Prayer Services
___Holy Book/Koran/Torah/Bible Study
87. How would you rate the importance of spirituality/religion to you? (0 –Unimportant to 10-Very
Important) ______________
88. How would your faith/spiritual status help or hinder your success with in-home counseling?
______________________________________________________________________________________
ACKNOWLEDGEMENT
________________________________
Client Name
______________________________
Signature
_____________
Date
________________________________
Parent/ Legal Guardian Name
______________________________
Signature
_____________
Date
________________________________
OCC In-Home Counselor Name
______________________________
Signature
_____________
Date
