Mind Body - CONFIDENTIAL MEDICAL INFORMATION

OPTIONAL INITIAL ASSESSMENT INFORMATION

Instructions: To assist us in understanding and helping you, please fill out this form as completely as possible. This information is confidential and only released with your permission.

Name ____________________________________________ Date _________________

Current Symptoms: (check those that are problematic to you)

___Angry outbursts ___Hallucinations ___Recurring behaviors

___Anxious feelings ___Health worries ___Recurring thoughts

___Appetite change ___Hopeless/helpless ___Self-harm

___Concentration difficulties ___Impulsive behaviors ___Sexual problems

___Crying spells ___Irritable ___Sleep problems

___Depressed mood ___Loneliness ___Suicidal thoughts

___Disorganized thoughts ___Money management ___Unable to experience

forgiveness

___Energy level changes ___Mood shifts ___Unable to pray

___Excessive guilt ___Not enjoying things ___Withdrawing

___Feel like hurting others ___Panic attacks ___Worrying excessively

Others (specify): _______________________________________________________________

____________________________________________________________________________

How do the symptoms you checked effect your daily functioning? ____________________________________________________________________________

____________________________________________________________________________

Personal Information:

What are your greatest strengths?

____________________________________________________________________________

What are your greatest weaknesses?

____________________________________________________________________________

Persons currently living in your home:

Name Age Relationship Quality of Relationship

_________________________ ______ _________________ Good Fair Poor

Children living out of your home: (if applicable)

Name Age Relationship Quality of Relationship

_________________________ ______ _________________ Good Fair Poor

Significant Supportive Relationships:

Name Age Relationship Quality of Relationship

_________________________ ______ _________________ Good Fair Poor

Marital Status: (check all that apply)

___Never married ___Committed partnership ___Legally married

Length of time _____ Length of time ____

___Separated ___Divorce in process ___Divorced

Length of time ____ Length of time ___ Length of time ___

___Widowed Total number of marriages (if applicable) ________

Length of time ___

Extended Family:

Name Age Living? Occupation Quality of Relationship

Father __________________ ___ No Yes _____________ Good Fair Poor

Mother __________________ ___ No Yes _____________ Good Fair Poor

Stepfather _________________ ___ No Yes _____________ Good Fair Poor

Stepmother_________________ ___ No Yes _____________ Good Fair Poor

Siblings __________________ ___ No Yes _____________ Good Fair Poor

Which of the following best describes the family in which you grew up? (Circle 1 number along the continuum below)

Warm & Accepting Average Hostile & Fighting

1 2 3 4 5 6 7 8 9 10

Trauma History:

Have you had a history of trauma or abuse? No Yes If yes, what type of abuse or trauma occurred?

___ Physical ___ Sexual ___ Emotional ___ Neglect Abuse was as: ___ Victim ___ Perpetrator

Social Relationships:

How do you usually get along with people?

___ Avoidant ___ Shy ___ Leader ___ Outgoing ___ Assertive ___ Follower ___ Irritable

Has there been a recent change in your attitude/relationships with others? No Yes If yes, circle the above words that describe that change.

What is your sexual orientation? ___ Heterosexual ___ Bisexual ___ Gay ___ Lesbian

Cultural/Ethnic Concerns:

Do you have concerns related to cultural or ethnic issues? No Yes If yes, explain: _____________________________________________________________________________________

Spiritual/Religious History:

In your experience, how important are spiritual matters? ____________________________________________

What is your present religious affiliation? _______________________________________________________

Do you have spiritual concerns that you would like to address in the therapy process? No Yes

Not Sure Describe: ____________________________________________________________________

Legal History: (if applicable)

Are you currently involved with the legal system? No Yes If yes, explain _____________________________________________________________________________________

_____________________________________________________________________________________

Have you been involved with the legal system in the past? No Yes If yes, explain _____________________________________________________________________________________

_____________________________________________________________________________________

Do you currently have a probation or parole officer? No Yes If yes, name _____________________________________________________________________________________

_____________________________________________________________________________________

Educational History: (check all that apply)

___Currently in school No Yes ___High School Grad/GED No Yes

___Vocational Graduated No Yes Major ______________

___Graduate School Graduated No Yes Major ______________

___College Graduated No Yes Major ______________

Did you experience any of the following problems in school? __Learning __Emotional __Discipline __Social

Do you currently experience any of the following learning barriers?

___ Learning disability ___ Vision impairment ___ Hearing impairment ___ Language

I learn best through: (check all that apply) ___ Discussion ___ Written materials ___ Videos ___ Tapes

What is your primary language? ___ English ___ Spanish ___ Sign ___ Other

Employment History: (complete those that apply)

List job history beginning with most recent job

Employer Dates Job Title Reason for Leaving

____________________________________________________________________________

Current Status: ___ FT ___ PT ___ Disabled ___ Laid off ___ Retired ___ Student ___ Homemaker

Other ____________________________________________________________________________________

Please check any current work related concerns:

___ Attendance problems ___ Performance problems ___ Work load ___ Medical leave

___ Employer Concerns ___ Potential for lay off ___ Dislike job ___ Relationship problems with

coworkers, employer, other

Military History:

Military experience No Yes If yes, specify branch and dates of service:

Branch ___________________ Date Enlisted _______________ Date Discharged________________

Leisure/Recreational:

Hobbies/Interests Recent change in frequency?

______________________________ __ No change __ Decreased frequency __ Increased frequency

Personal Counseling/Treatment History:

Please provide past and present information.

No Yes When Purpose Result

Counseling/Psychiatric Treatment _______________ _______________ ______________

____________________________________________________________________________

Drug/Alcohol Treatment _______________ _______________ ______________

____________________________________________________________________________

Hospitalizations _______________ _______________ ______________

____________________________________________________________________________

Self-help Groups _______________ _______________ ______________

____________________________________________________________________________

Family/Significant Others Counseling/Treatment Information: