Important - Please Read: This questionnaire is designed as a tool to assist you and your therapist in developing the most effective plan to resolve your personal concerns. It is not necessary to answer all of the questions if you do not wish to do so. The information you include about yourself and your family is confidential. It is encrypted before it is submitted. No one else will be able to read it. Your Name * Date Completed * Phone # * DOB: * Ok to call this # and leave message? Yes No Email Address: May I contact you via email? Home Address: * Part I. Presenting Data Briefly describe your reason for contacting me * How long has this been a problem for you? * What have you tried previously to resolve the problem? * What made you decide to seek help at this time? * What do you hope will be happening more or more often as a result of your coming here? Be as specific as possible. * Who is most responsible for your coming here at this time? * Many people notice a significant change, for better or worse, have occurred in their lives within the 12 months prior to their beginning counseling. What significant changes have occurred in your life in the last 12 months? Part II. Present Situation Marital Status Who resides in the current household? (spouse, children, stepchildren, others) Do you have any hobbies, leisure activities, exercise programs, etc. ? If yes, what are they? What is your religious preference? Degree of involvement? Do you view is as an area of concern for you? Part III. Medical and Physical History Please list any significant medical conditions (asthma, diabetes, high blood pressure, surgeries, etc) Please list current medications (name, dosage and how often taken) Are you currently under the care of a physician? If yes, list MD name and phone number. How would you characterize your size? Very Thin Thin Average Over weight Very overweight Part VI. Legal, Financial, Military History List any pending legal problems and past legal problems List any financial concerns Have you ever been in the armed forces? If yes, were you ever in active combat? Part VII. Alcohol and Drug Use Have you ever felt like you should cut down on your alcohol or other drug use? * Yes No Has a friend or relative expressed concerns about your use? * Yes No Have you ever felt guilty about your drinking or drug use? * Yes No Have you ever had to take a drink or use a drug the next day to steady your nerves? * Yes No Are you a recovering alcoholic or recovering drug addict? * Yes No Is there a history of problems with alcohol or drug use in your family? (Brothers, sisters, parents, grandparents) * Yes No Family member(s) with alcohol and/or drug problems On average, how many days per week do you drink alcohol or use drugs? * On a typical day when you drink, how many drinks do you have? * What’s the maximum number of drinks you had on a given occasion in the last 30 days? * Check any of the following you have used in the past or currently: * Alcohol Marijuana Cocaine Heroin Pain killers Sleeping pills Valium, Librium, Xanax, Klonapine Amphetamines (speed, meth) Hallucinogens Have used NONE of the above Have you ever used any of the following as a means of weight control? Laxatives Diuretics Diet Pills Exercise Vomiting Part IV Physical and Emotional Health Check any of these experienced * Headaches Painful intercourse Night sweats Persistent pain Chest pain Tingling Painful urination Muscle Aches Persistent cough Diarrhea Allergies drug Dizziness Frequent urination Loss of balance Spitting up blood Tremors Heart palpitations Yellowing of eyes Shortness of breath Swelling Special diet needed Seizures Vomiting Numbness Memory problems People following me out to hurt me Thoughts faster than I can think Confusion People reading my thoughts Problems knowing where I am Hearing voices Seeing things that are not there People talking about me Allergies food People talking about me Losing interest in sex Feeling I am no good Intense guilt Uncontrollable crying Low energy Unintended weight loss Losing pleasure in daily activities Feeling helpless Feeling hopeless Thoughts of killing self Urge to harm self Suicide attempts Mood swings Preoccupied with sex Increased alcohol use Needing more sleep Insomnia Going long periods without sleep Compulsive spending or gambling Increased drug use Increased smoking Compulsive behavior Urge to harm others Difficulty controlling temper Troubled by painful memories Feeling detached Feel things are unreal Feeling alienated Recurring nightmares Easily startled Worrying about a catastrophe Excessive cleaning or checking I have NEVER experienced ANY of the above