Intake Questionnaire For New Patients (Adult) Step 1 of 9 11% Welcome. I’m pleased that you have chosen to take this step. I look forward to working with you. This questionnaire is for the purpose of getting to know you better in order to provide the best possible mental health services. Please complete this form as honestly and completely as possible. All information that you provide us will be confidential as required by state and federal law. Personal InformationDate:* MM slash DD slash YYYY Social Security Number:* Legal Name:* Preferred Nickname* Age:* Date of Birth:* MM slash DD slash YYYY Birthplace* Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Phone*Cellular/Alternate Phone:*Personal Email* May I leave a message on your home phone?* Yes No May I leave a VM on your cellphone?* Yes No Text?* Yes No May I email you?* Yes No *Note: Email correspondence and texts are not guaranteed as a confidential method of communication. If you choose to use either one, please be sure to limit it to details like scheduling as well as billing ONLY. Please DO NOT send an email to cancel or confirm a scheduled appointment. Please ONLY text me to confirm, cancel or change an appointment (48 hours cancelation policy still applies though. Third party payers do not cover late cancelations or missed appointments, which would become your sole responsibility, regardless of whether you choose to use your insurance or not). Additionally, unless in case of a true emergency, I may choose not to respond to the question outside of an appointment, unless strictly related to rescheduling or billing, as I do not provide email or text therapy. Thank you for respecting this professional boundary.Can we please have a signature below: Please sign here that you acknowledge, clearly understand, and agree with the missed appointment, late cancelation and e mail/text policies:*Please take a picture of your signature and upload it(Additional option)Accepted file types: jpg, gif, png, pdfdoc, Max. file size: 256 MB.Referred by/how did you find me?:* Marital Status:* single married separated divorced remarried engaged widowed cohabiting If applicable, please complete the following: Partner’s Name: Partner’s Age: Partner’s Occupation: IF YOU HAVE CHILDREN PLEASE LIST THEIR NAMES AND AGES:NameSexAge WHO CURRENTLY LIVES IN YOUR RESIDENCE (adults and children)NameRelationSexAge Emergency Contact InfoEmergency Contact Info*NameRelationshipAddressHome #Cell #Work Telephone #Employer Medical Contact Info*Primary PhysicianPhone #Psychiatrist/SpecialistPhone #Physician/SpecialistPhone # Please check* I have voluntarily provided the above contact information and authorize Dr. Gilbert Chalepas and his representatives to contact any of the above on my behalf in the event of an emergency. I choose not to provide any emergency contact information to Dr Gilbert Chalepas at this time. Client Signature*Please take a picture of your signature and upload it(Additional option)Accepted file types: jpg, gif, png, pdfdoc, Max. file size: 256 MB.Date* MM slash DD slash YYYY Please select* If you plan to use your insurance, please be aware that insurance companies typically only cover services that are declared as a medical necessity. In other words, your clinician Dr. Gilbert Chalepas, is required to diagnose you with a verifiable mental illness in order for the services to qualify for coverage under your insurance. Many plans also require that annual deductibles be met by patients first, prior to paying for any services. If an insurance company decides to do an audit on your records in an attempt to prevent fraud, they would have access to details about what happened during each of your therapy sessions and other private details that patients would normally prefer to be left confidential. Furthermore, any documented health treatment filed through your insurance is required to be recorded on your permanent medical record and may become a pre-existing condition. If you agree, please select If you would prefer to pay out of pocket (cannot be used towards meeting your annual out of pocket insurance deductible in any way), you are guaranteed that the only people who know any of the details of your therapy are you and your clinician, Dr. Gilbert Chalepas. Aside from normal limits to confidentiality, this way therapy is completely confidential, without any third party being privy to information exchanged in your sessions. If you agree, please select In your own words, describe your current problems/challenges as you see them and the reasons why they are happening:*How long has this been going on?* What made you reach out at this particular time?*What do you hope to gain from this evaluation and/or counseling?*If you had difficulties in the past, what have you done to cope? Was it helpful? SymptomsPlease check any symptoms or experiences that you have had in the last month* Difficulty falling asleep Difficulty staying asleep Difficulty getting out of bed Not feeling rested in the morning Average hours of sleep per night:* Usual bedtime* Usual wake-up time* What do you think contributes to your sleeping difficulties?* How long have your sleeping difficulties been occurring?* What have you tried so far to make your sleep/rest better?* * Persistent loss of interest in previously enjoyed activities Withdrawing from other people Spending increased time alone Depressed Mood Feeling Numb Rapid mood changes Abnormally upbeat, jumpy or wired Increased activity, energy or agitation Exaggerated sense of well-being and self-confidence (euphoria) Decreased need for sleep Unusual talkativeness Racing thoughts Distractibility Poor decision-making — for example, going on buying sprees, taking sexual risks or making foolish investments Irritability Anxiety Panic attacks Frequent feelings of guilt Avoiding people, places, activities or specific things Difficulty leaving your home Outbursts of anger Repetitive behaviors or mental acts (i.e., counting, checking doors, washing hands) Fear of certain objects or situations (i.e., flying, heights, bugs) * Worthlessness Hopelessness Sadness Helplessness Fear Feeling or acting like a different person * Changes in eating/appetite Eating more Eating less Voluntary vomiting Use of laxatives Excessive exercise to avoid weight gain Binge eating Are you trying to lose weight?* Yes No Recent weight gain:* Recent weight loss:* How do you feel about your current weight or appearance?* * Difficulty catching your breath Increase muscle tension Unusual sweating Easily started, feeling “jumpy” Increased energy Decreased energy Tremor Dizziness Frequent worry Physical sensations others don’t have Racing thoughts Intrusive memories Difficulty concentrating or thinking Large gaps in memory Flashbacks Nightmares Thoughts about harming or killing yourself Thoughts about harming or killing someone else * Difficulty problem solving Difficulty meeting role expectations Dependency on others Manipulation of others to fulfill your own desires Inappropriate expression of anger Self-mutilation/cutting Difficulty or inability to say “no” to others Ineffective communication Sense of lack of control Decreased ability to handle stress Abusive relationship Difficulty expressing emotions Concerns about your sexuality * Feeling as if you were outside yourself, detached, observing what you are doing Feeling puzzled as to what is real and unreal Persistent, repetitive, intrusive thoughts, impulses, or images Unusual visual experiences such as flashes of light, shadows Hear voices when no one else is present Feeling that your thoughts are controlled or placed in your mind Feeling that the television or the radio is communicating with you Sexual Orientation:* Heterosexual Homosexual Bisexual Pansexual Asexual Polysexual Graysexual Transexual Intersex I choose not to answer Please describe any related issues or challenges to your sexual orientation.*Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?* Yes No *Name of therapist:Reason for seeking help:Dates of Treatment:Was it helpful?What could have been better?Reason for leaving?Rate your overall experience 1-10 Describe that process and if it was helpful:*Are you CURRENTLY taking PSYCHIATRIC medications?* Yes No *MedicationDosagePurposeHow long have you been taking it?Has it been helpful?Any side effects Are you CURRENTLY taking NON-PSYCHIATRIC medications?* Yes No *MedicationDosagePurposeHow long have you been taking it?Any side effects Have you been on PSYCHIATRIC medication in the past?* Yes No *MedicationDosagePurposeFirst/Last time you took itEffect of MedicationAny side effects Have you been hospitalized for psychiatric reasons?* Yes No *HospitalDatesReason Have you ever tried to injure yourself purposely to relieve emotional pain?* Yes No Please explain:*Have you ever had or currently have suicidal or homicidal thoughts?* Yes No Thoughts about suicide. Can be active or passive and can be with or without intent or a plan. Passive: General feelings of not wanting to be alive Active: Wanting to commit suicide in the present, often times with a specific plan and intent (having the intention of completed suicide)*When?Please describe: Have you ever attempted to take your own life?* Yes No *When?Please describe: 1. In the past few weeks, have you wished you were dead?* Yes No 2. In the past few weeks, have you felt that you or your family would be better off if you were dead?* Yes No 3. In the past week, have you been having thoughts about killing yourself?* Yes No 4. Have you thought about how you would kill yourself?* Yes No Have you thought about when you would kill yourself?* Have you thought about what to write in a suicide note?* Have you thought about writing your will?* Have you thought about telling other people that you planned to kill yourself?* Have you thought about how people would feel if you killed yourself?* 5. Are you having thoughts of killing yourself right now?* Yes No Please describe:*If you don’t feel safe around yourself, please call 911 immediately or go your nearest hospital or emergency room, please avoid drugs and alcohol, make your home safe by getting rid of all knives, razors, pills, and any firearms. Please don’t keep those suicidal feelings to yourself! If you don’t know who to turn to: In the U.S. – Call the 24/7 National Suicide Prevention Lifeline at 1-800-273-TALK (8255) En Español: 1-888-628-9454 or the 24/7 National Hopeline Network at 1-800-SUICIDE (1-800-784-2433) or 24/7 Crisis Text Line: Text “HOME” to 741-741 FAMILY HISTORYFatherSelect* Living Deceased Age:* If deceased, HIS age at time of his death* YOUR age at time of his death* Occupation:* Health:* Frequency of contact with him:* Are you/Have you been close to him?* MotherSelect* Living Deceased Age:* If deceased, HER age at time of his death* YOUR age at time of HER death* Occupation:* Health:* Frequency of contact with her:* Are you/Have you been close to her?* Parents’ Current Marital Status:* Married to each other Separated Divorced Mother remarried Father remarried Mother involved with someone Father involved with someone Mother deceased Father deceased Childhood Family Experience:* Outstanding home environment Normal home environment Chaotic home environment Neglected Witnessed physical/verbal/sexual abuse towards others Experienced physical/verbal/sexual abuse from others Brothers and SistersNameSexAgeWhereaboutsAre you close to him/her? YesNo During your childhood, did you live any significant period of time with anyone other than your natural parents?* Yes No please give the person’s name and relationship to you* SOCIAL HISTORYAre you in a committed relationship?* Yes No For how long?* On a scale of 1-10, rate your relationship* Describe any issues:*Are you currently, or at any other time, been in an open relationship?* Yes No Please elaborate:*If single, do you prefer being single or would you rather be in a relationship? Please elaborate:*What do you think stands in your way, if being in a relationship is important to you? Please elaborate*Past Marital History Have you been married previously?* Yes No *When?How long?Reason for divorce/breakup?Any residual feelings about it? EducationHighest grade level completed:* Degree obtained, if applicable: Did you have any disciplinary problems in school?* Yes No please explain:* Were you considered hyperactive/ADHD in school?* Yes No If yes, were/are you on any medication?* What kinds of grades did you get in school?* Employment Are you currently employed?* Yes No Employer’s name:* What type of work do you do?* Average hours per week?* Do you enjoy your work?* Please describe any issues related to your current job:* What do you hope to be doing five/ten years from now?* Employment History (most recent first)*Type of JobDatesReason for Leaving Have you ever been arrested?* Yes No Please elaborate:* Do you have a religious affiliation?* Yes No what is it?* What kind of social activities do you participate in?* Who do you turn to for help with your problems?* Have you ever been abused?* Verbally Emotionally Physically Sexually Neglected Never Please describe:Social Support System:* supportive network few friends substance-use-based friends no friends distance from family of origin Financial Situation:* no current financial problems large indebtedness poverty or below-poverty income impulsive spending relationship conflicts over finances Have you served in the military?* Yes No please describe briefly:* What type of discharge (separation) did you get?* Do you currently have or previously had a pet?* Yes No *Pet's nameAgePlease describe the relationship you shared with your pet SUBSTANCE ABUSEAlcoholDo you drink alcohol?* Yes No Age of first use* How much do you drink?* How often do you drink?* Have you ever passed out from drinking?* Yes No How often?* Have you ever blacked out from drinking?* Yes No How often?* Have you ever had the “shakes”?* Yes No How often?* Have you ever felt you should cut down on your drinking/drug use?* Yes No Have people annoyed you by criticizing your drinking/drug use?* Yes No Have you ever felt bad or guilty about your drinking/drug use?* Yes No Have you ever drank/used drugs in the morning to steady your nerves or relieve a hangover?* Yes No TobaccoDo you use tobacco?* Yes No How often?* When did you start?* Have you ever wanted/tried to quit?* Yes No Please elaborate:* CaffeineDo you regularly consume caffeine?* Yes No *Coffee/Espresso?Hot chocolate?Caffeinated teas?Sodas?Energy Drinks?Pre-workout drinks?How many ounces per day of each?How about over the counter medications which contain caffeine (i.e. Vivarin, NoDoz, Midol, Excedrin, Appetite Suppressants, etc.)?*For what purpose would you consume a caffeinated beverage or medication? (Please select all that apply.)* To feel more awake To stay up late To help with focus and concentration To be more alert To be more productive To improve physical performance No specific purpose Prefer not to answer When do you have the most consumption of caffeine?* morning afternoon evening night How do you think caffeine consumption impacts your sleep and mood?* Could you go 48-72 hours without caffeine?* Yes No Recreational DrugsDo you use recreational drugs?* Yes No CANNABIS Marijuana Hash Oil Pot Weed Blow STIMULANTS Cocaine Crack Blow Methamphetamine — meth Ice Crank AMPHETAMINES/OTHER STIMULANTS Ritalin Benzedrine Dexedrine Speed Bennies Uppers BENZODIAZEPINES/ TRANQUILIZERS Valium Librium Xanax Diazepam Roofies Downers SEDATIVES/HYPNOTICS/BARBITURATES Amytal Seconal Dalmane Quaalude Phenobarbital HEROIN Smack Scat Brown Sugar Dope STREET OR ILLICIT METHADONEOTHER OPIOIDS Tylenol #2 & #3 Percodan Percocet Opium Morphine Demerol Dilaudid HALLUCINOGENS LSD PCP Mescaline Peyote Mushrooms Ketamine Ecstasy (MDMA) INHALANTS Glue Gasoline Aerosols Paint thinner Poppers Rush Whippets STEROIDS Deca-Durabolin Durabolin Equipoise Winstrol Anadrol Oxandrin Roids Juice Prescription MedicationsDo you use prescription medications in a way that they were not intended or prescribed?* Yes No Describe:* Other DrugsPlease indicate for each drug listed belowMarijuanaEver Used?Age at 1 st useTime Since Last UseApprox use in last 30 daysCocaineEver Used?Age at 1 st useTime Since Last UseApprox use in last 30 daysCrackEver Used?Age at 1 st useTime Since Last UseApprox use in last 30 daysHeroinEver Used?Age at 1 st useTime Since Last UseApprox use in last 30 daysMethamphetamineEver Used?Age at 1 st useTime Since Last UseApprox use in last 30 daysEcstasyEver Used?Age at 1 st useTime Since Last UseApprox use in last 30 daysOtherEver Used?Age at 1 st useTime Since Last UseApprox use in last 30 days SUBSTANCE USE HISTORYHave you ever felt you should cut down on your drug use?* Have people annoyed you by criticizing your drug use?* Have you ever felt bad or guilty about your drug use?* Substance Use Status:* No history of abuse Active abuse Early full remission Early partial remission Sustained full remission Sustained partial remission Treatment History:* Outpatient Inpatient 12-step program Stopped on own Other: Substances Used (check all that apply) AlcoholFirst use ageLast use ageCurrently Used?FrequencyAmountNoYesAmphetamines/SpeedFirst use ageLast use ageCurrently Used?FrequencyAmountNoYesBarbituratesFirst use ageLast use ageCurrently Used?FrequencyAmountNoYesCaffeineFirst use ageLast use ageCurrently Used?FrequencyAmountNoYesCocaineFirst use ageLast use ageCurrently Used?FrequencyAmountNoYesCrack CocaineFirst use ageLast use ageCurrently Used?FrequencyAmountNoYesEcstasyFirst use ageLast use ageCurrently Used?FrequencyAmountNoYesHallucinogens (LSDFirst use ageLast use ageCurrently Used?FrequencyAmountNoYesHeroinFirst use ageLast use ageCurrently Used?FrequencyAmountNoYesInhalantsFirst use ageLast use ageCurrently Used?FrequencyAmountNoYesMarijuanaFirst use ageLast use ageCurrently Used?FrequencyAmountNoYesMethadoneFirst use ageLast use ageCurrently Used?FrequencyAmountNoYesMethamphetamineFirst use ageLast use ageCurrently Used?FrequencyAmountNoYesPainkillersFirst use ageLast use ageCurrently Used?FrequencyAmountNoYesNicotine/TobaccoFirst use ageLast use ageCurrently Used?FrequencyAmountNoYesPCPFirst use ageLast use ageCurrently Used?FrequencyAmountNoYesTranquilizersFirst use ageLast use ageCurrently Used?FrequencyAmountNoYesOther:First use ageLast use ageCurrently Used?FrequencyAmount NoYes Have you ever felt you needed to cut down on your alcohol or drug use?* Yes No Has anyone criticized your use or shared concerns about it?* Yes No Have you felt guilty, worried, or stressed about your drinking or drug use?* Yes No Describe any alcohol or drug related details or concerns:* Any other issues related to drugs/alcohol or other self-destructive behaviors you'd like us to work on?* Rate your current physical health?* Poor Unsatisfactory Satisfactory Good Describe health:*Hobbies, interests, or exercise you regularly participate in?*Please describe activity and frequency:*Describe, if any, other addictive or compulsive type (internet, excessive gaming, gambling, sex, shopping, substances) behaviors?How would you describe your uses of technology or online time and experiences?*What significant life changes or events have you experienced?*Have you already or are you planning to apply for disability in the near future?* Yes No Please explain:* Have you had or do you currently have any legal issues?* Yes No Describe:* Current Symptoms ChecklistPlease check severity of symptoms, including if they are improving or notAggression Mild Moderate Severe Improving Getting Worse Agitation Mild Moderate Severe Improving Getting Worse Anger Mild Moderate Severe Improving Getting Worse Anxiety Mild Moderate Severe Improving Getting Worse Appetite change Mild Moderate Severe Improving Getting Worse Change in libido Mild Moderate Severe Improving Getting Worse Compulsions Mild Moderate Severe Improving Getting Worse Crying/tearful Mild Moderate Severe Improving Getting Worse Cyber addiction Mild Moderate Severe Improving Getting Worse Delusions Mild Moderate Severe Improving Getting Worse Depression Mild Moderate Severe Improving Getting Worse Disorientation Mild Moderate Severe Improving Getting Worse Difficulty getting out of bed Mild Moderate Severe Improving Getting Worse Difficulty making decisions Mild Moderate Severe Improving Getting Worse Distractibility Mild Moderate Severe Improving Getting Worse Eating disorder Mild Moderate Severe Improving Getting Worse Elevated mood Mild Moderate Severe Improving Getting Worse Emotional trauma perpetrator Mild Moderate Severe Improving Getting Worse Emotional trauma victim Mild Moderate Severe Improving Getting Worse Excessive energy Mild Moderate Severe Improving Getting Worse Fatigue Mild Moderate Severe Improving Getting Worse Grief Mild Moderate Severe Improving Getting Worse Guilt Mild Moderate Severe Improving Getting Worse Gambling Mild Moderate Severe Improving Getting Worse Hallucinations Mild Moderate Severe Improving Getting Worse Hearing voices Mild Moderate Severe Improving Getting Worse Heart palpitations Mild Moderate Severe Improving Getting Worse Hopelessness Mild Moderate Severe Improving Getting Worse Hyperactivity Mild Moderate Severe Improving Getting Worse Impulsivity Mild Moderate Severe Improving Getting Worse Irritability Mild Moderate Severe Improving Getting Worse Judgment errors Mild Moderate Severe Improving Getting Worse Loneliness Mild Moderate Severe Improving Getting Worse Loss of interest in activities Mild Moderate Severe Improving Getting Worse Memory impairment Mild Moderate Severe Improving Getting Worse Mood swings Mild Moderate Severe Improving Getting Worse Obsessions Mild Moderate Severe Improving Getting Worse Oppositional behavior Mild Moderate Severe Improving Getting Worse Panic attacks Mild Moderate Severe Improving Getting Worse Paranoia Mild Moderate Severe Improving Getting Worse Phobias/fears Mild Moderate Severe Improving Getting Worse Physical trauma perpetrator Mild Moderate Severe Improving Getting Worse Physical trauma victim Mild Moderate Severe Improving Getting Worse Poor concentration Mild Moderate Severe Improving Getting Worse Poor grooming Mild Moderate Severe Improving Getting Worse Racing thoughts Mild Moderate Severe Improving Getting Worse Recurring thoughts Mild Moderate Severe Improving Getting Worse Self-mutilation Mild Moderate Severe Improving Getting Worse Sexual addiction Mild Moderate Severe Improving Getting Worse Sexual difficulties Mild Moderate Severe Improving Getting Worse Sexual trauma perpetrator Mild Moderate Severe Improving Getting Worse Sexual trauma victim Mild Moderate Severe Improving Getting Worse Sleep problems Mild Moderate Severe Improving Getting Worse Speech problems Mild Moderate Severe Improving Getting Worse Social isolation Mild Moderate Severe Improving Getting Worse Substance abuse Mild Moderate Severe Improving Getting Worse Suicidal thoughts Mild Moderate Severe Improving Getting Worse Worried Mild Moderate Severe Improving Getting Worse Worthlessness Mild Moderate Severe Improving Getting Worse Personal and Family Medical HistoryAre you CURRENTLY under treatment for any medical condition?* Yes No Please describe*List any PRIOR illnesses, operations and accidents* Have you or a family member ever had any of the following? If family, specify which family memberAlzheimer’s/Dementia You Family Who? Anemia You Family Who? Arthritis You Family Who? Asthma You Family Who? Behavioral problems You Family Who? Birth defects You Family Who? Cancer You Family Who? Chronic Fatigue You Family Who? Chronic Pain You Family Who? Diabetes You Family Who? Ear/Nose/Throat Problems You Family Who? Eating Disorder You Family Who? Emotional Problems You Family Who? Endocrine/Hormone Problems You Family Who? Epilepsy or Seizures You Family Who? Eye Problems You Family Who? Fibromyalgia You Family Who? Gastrointestinal Problems You Family Who? Genital/Gynecological Problems You Family Who? Head Injury You Family Who? Heart Disease You Family Who? High Blood Pressure You Family Who? High Cholesterol You Family Who? HIV Positive or AIDS You Family Who? Kidney Problems You Family Who? Liver Problems/Hepatitis You Family Who? Lung Disease You Family Who? Mental Retardation You Family Who? Migraine or Cluster Headaches You Family Who? Neurological Problems You Family Who? Skin Disease You Family Who? Sleep Apnea You Family Who? Stroke You Family Who? Thyroid Disease You Family Who? Tuberculosis You Family Who? Urological Problems You Family Who? Viral Illness/Herpes You Family Who? Has anyone in your family ever been treated for any of the following?FatherMotherAuntUncleBrotherSisterChildrenGrandparentDepressionAnxietyPanic AttacksPost Traumatic StressBipolar Disorder/Manic DepressionSchizophreniaAlcohol ProblemsDrug ProblemsADHDSuicide AttemptsPsychiatric HospitalizationNervous ProblemsHyperactivityCounselingPsychiatric MedicationDeath by Suicide Past Psychiatric MedicationsHave you ever taken Psychiatric medications?* Yes No Who prescribes your psychiatric medications?* Your primary care physician or psychiatrist?* AntidepressantsProzac (fluoxetine)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesZoloft (sertraline)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesLuvox (fluvoxamine)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesPaxil (paroxetine)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesCelexa (citalopram)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesEffexor (venlafaxine)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesCymbalta (duloxetine)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesWellbutrin (bupropion)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesRemeron (mirtazapine)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesSerzone (nefazodone)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesAnafranil (clomipramine)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesPamelor (nortrptyline)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesTofranil (imipramine)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesElavil (amitriptyline)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesPristiq (desvenlafaxin)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesViibryd (vilazodone)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesAdapin (doxepin)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesAsendin (amoxapine)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesLudiomil (maprotiline)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesNorpramin (desipramine)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesSurmontil (trimipramine)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesVivactil (protriptyline)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesAntipsychotics/Mood StabilizersSeroquel (quetiapine)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesZyprexa (olanzapine)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesGeodon (ziprasidone)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesAbilify (aripiprazole)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesClozaril (clozapine)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesHaldol (haloperidol)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesProlixin (fluphenazine)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesSedative/HypnoticsAmbien (zolpidem)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesSonata (zaleplon)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesRestoril (temazepam)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesRozerem (ramelteon)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesDesyrel (trazodone)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesADHD MedicationsAdderall (amphetamine)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesConcerta (methylphenidate)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesRitalin (methylphenidate)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesStrattera (atomoxetine)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesAntianxiety MedicationsXanax (alprazolam)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesAtivan (lorazepam)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesKlonopin (clonazepam)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesValium (diazepam)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesTranxene (clorazepate)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesBuspar (buspirone)Did you take?When?Dosage?Did it help?Any side effects?NoYesNoYesNoYesOther Medications (specify)OtherDid you take?When?Dosage?Did it help?Any side effects? NoYesNoYesNoYes What do you consider to be some of your strengths or areas in your life that are going well?*What do you consider to be some of the areas you need to improve?*What do hope to accomplish out of your time in therapy?*What may happen if you don’t change/address the issues that brought you here?*How will you know therapy is working?*Is there anything specific you want as an outcome?*What might keep you from getting where you want to go?*In six months, if things were going exactly the way you want, what would you see?*What compromises are you willing to make in order to reach your goal(s) in the next three to six months? Please be very specific*Please honestly rate your personal level of commitment regarding your transformation in therapy 1-10, and the reason(s) why is it so?*CAPTCHA Δ CALL NOW TO SCHEDULE A CONSULTATION FOR ADULT INTAKE +1 (310) 500 8442 Drop Us A Line Or Request An Appointment [wpforms id=”3961″ title=”false” description=”false”] Contact Us Now California Headquarters 1550 Bayside Dr Corona Del Mar, CA 92625 Phone: +1 (310) 500 8442 Email Us Florida Headquarters 150 E Palmetto Park Road, Suite 800 Boca Raton, FL 33432 Phone: 1+ (561) 816 7360 Email Us
