Welcome New Clients!

Welcome to Full Circle Behavioral Health, PC., where we strive
to enable those committed to themselves.
Be Your Best Self and Feel Truly Alive!

We try our best to make your experience as stress-free as possible.
We are aware of the anxiety that can be produced upon entering
therapy for the first time or meeting a new therapist. Therefore,
instead of sitting in our waiting room filling out the needed
paperwork for you to get started, the form is provided for you
below. This enables you to fill out the paperwork at your
convenience and in the privacy of your environment. It also affords
you ample time to carefully reflect on your answers, past experiences,
and feelings to better facilitate accurate answers.

Your first visit will encompass a review of your history, as you provided,
an exploration of your discomfort, to afford a diagnosis, which is
necessary if you are utilizing your insurance, and the ability for you to
tell your story.

At the end of the session the therapist will provide you with your diagnosis,
which can be modified if need be, if more information becomes available,
and a workable, agreeable treatment plan that you helped to create for
yourself. This includes your goals for yourself and what you would like to
achieve in therapy.

Below is the intake form you will need to fill out to get started. You will
need to copy and paste this form into a word document,and enable your
insert function to erase the lines provided, while typing in your answers
where the lines are. Also, enable the underline function as well so your
answers will be underlined. I hope this helps to make your experience as
stress-free as possible! I look forward to meeting with you.

Psychosocial and Medical History Report

Please Print

Name of client: _____________________________________________

If a child, parent's names including step-parents:________________


Address: ____________________________________ City: _____________
Zip ___________

Home Phone ( )_________________Cell: ( )____________________
Bus. ( )__________________

Gender: _______ Race: __________________ Religion: ______________

Employed?_______ Employer: ___________________________________

Employer Address:_____________________________________________

Position:___________________________________Duration: __________

Date of Birth: _____________________________ Age:_______

Referred by: _____________________________________
Yodle____Physician _________Yahoo____Google____Bing____MSN____
Yellow pages______ Friend (Who) _________________________________

Reason for seeking treatment at this time?___________________________


What would you like to achieve from treatment?______________________

How long do you think it will take to resolve this issue/problem?

Describe your personal strengths: ____________________________________

List family or friends you would like involved in your treatment: _______________________________________________________________________

Are family and friends aware of your decision to come here? _______________________________________________________________________
Family History

Mother’s age: _____ Deceased, your age: _____Her age at your birth: ______
Occupation: __________ Father’s age: _____ Deceased, your age: _____ His age at your birth: ______

Number of brothers_____ sisters _____ deceased, who? And your age,
then: ________________________________________________________________

Number of half brothers _____ Sisters _____ on who’s side?______________

Parents divorced? _______ If yes, your age, then, _______ Your age when
Mother remarried ________

Your age when father remarried ______ Who did you live with?

Who raised you?__________ Your place in birth order __________
Where were you born? ________________________________

Describe your relationship with your:

Mother: ____________________________________________________________

Father: _____________________________________________________________

Brothers: ___________________________________________________________

Sisters: _____________________________________________________________

Stepmother: ________________________________________________________

Stepfather: _________________________________________________________

Stepsiblings: _______________________________________________________

Half siblings: _______________________________________________________

Grandparents: ______________________________________________________

Culture, Ethnicity, Spirituality, Religion
Describe any cultural, ethical, or religious concerns that might influence
your treatment: ______________________________________________________

Does spirituality influence your life? _____ Religious Preference: ________
Active? ____

Limitations Affecting Treatment
Do you have a disability or limitation which may affect your ability to
participate in treatment services, ie. Visual or auditory impairment?____
Is your primary language English? _____If No what is it?________________

Childhood Development

Did you have serious illnesses/problems or injuries as a child?
No_____ Yes_____ Please explain ___________________________________

Abuse History
Have you ever been physically, emotionally, or sexually abused? ______ If yes, was it reported? ______

How old were you at the time of the abuse? Who was/were the perpetrator(s)? _____________________

Have you ever abused another person? IF yes, How and when? _________________________________


Are you currently in a relationship? ________ Duration: ______________ Are you sexually active? ________ What is your sexual

orientation? Hetero _____ Homo _____ Bi _______ Are you comfortable with your sexuality? _______

Are you comfortable with your Gender? ________ If No to either, please explain _____________________________________________________

List all past and significant relationships/marriages: age, duration, # of children, and name of significant other, ______________________ __________________________________________________________________

Highest grade completed _____ Did you attend tech/trade school?____ Area of Study? ______________

Were you in special education classes? ____ Are you currently in school? ____ Area of Study? __________________________________________
Previous employment? ______________________________________________

Reasons for leaving: _____________________________________________________________________

Have you been in the armed forces?_____ If yes, when? _____________ Branch __________________

Duty: ___________________ Rank: ______________________ Honorable discharge? _____________

Have you ever been arrested? _____ If yes, please list all offenses, and result: ______________________________________________________________

Do you have a pending case? _____ Are you seeking therapy for court? ____ Are you on probation/parole at this time? __________ If yes dates of term: _____________________________________________________________________

How would you describe your friendships?____________________________

Describe your typical daily activities: ______________________________________________________________________

What activities do you enjoy ? ___________________________________________________________

What recreational activities do you participate? _____________________________________________

Do you currently have financial problems? _____ Please explain: _______________________________

Treatment History
Have you previous participated in therapy? _____ If yes, when and why? ____________________________________________________________________ ____________________________________________________________________

Do you attend any self-help groups? ____ If yes, name of group and frequency:___________________________________________________________

Mental Health
Are you experiencing any of the following? Depression ____, Anxiety _____, Frequent fears _____,

Guilt ____, Poor sleep ____, Mood swings ____, Nervousness ____, Anger ____, Low self-worth _____

Hearing voices/noises in your head____, Panic____, Seeing things that you question____, Cutting____

Is someone trying to hurt you? ___ If yes, explain ___________________________________________________________________

Do you currently have thoughts of suicide? _____ If yes, what would you do? _________________________________________________________


Have you ever attempted suicide? _____, If yes, when and what did you do? _________________________________________________________


Do you currently have thoughts of hurting someone? _____ If yes, who and how? __________________________________________________________


Have you hurt someone in the past? ___ If yes, who and how? _____________________________________________________________________

Substance Use
Do you drink alcohol?____ If yes, how much, type, and frequency? _____________________________
What is your highest period of use?______________________________

Do you use drugs? ___ If yes, how much, type, and frequency? ________________________________
what is your highest period of use: ______________________________

Do you feel you have a substance abuse problem? Unsure? Explain your answer: _____________________________________________________

Have you used any substances in the last 48 hours? ____ If yes, type and quantity: ____________________________________________________

Please list family members who you suspect or know have substance use problems and if they are still using: ____________________________________________________________________


Medical History:

Current diagnosed health conditions_______________________________ __________________________________________________________________
List medications are you currently taking and their doses: __________ ___________________________________________________________________ ___________________________________________________________________
List past medications: _____________________________________________ ___________________________________________________________________ List hospitalizations:_______________________________________________ ___________________________________________________________________ List past medical conditions or injuries:_____________________________ ___________________________________________________________________
Significant family medical and psychological history:________________ ___________________________________________________________________
Parents of Children and Adolescents As you are painfully aware, mental health and substance abuse problems can be devastating when left untreated. We all know that when a problem is addressed early it is much easier to find solutions. We ask that you take a few additional moments to think about your children/child.

We know that there are certain situations that put a child at a greater risk of developing mental health and/or substance abuse problems. The following “red flags” are provided to help you evaluate whether your child/children may be at risk. If within your household any or several of the following situations exist, please strongly consider requesting an evaluation for you child/children.

___ADD/ADHD/school problems/teacher concern ___child in mental health/substance use therapy
___disabling illness in child/teen
___difficulty with divorce issues
___drug/alcohol abuse in a parent/guardian
___sexual/emotional/physical abuse/neglect
___periods of homelessness
___foster care/child care by other than relatives
___multiple family relocation
___jail/prison for a guardian or parent
___ Death of child/teen’s family member/friend
___latch-key issues
___Child/teen being bullied
___major financial problems
___teen/child abortion/pregnancy
___mental illness in a parent/guardian
___teen/child abusive relationships
___spousal/significant other abuse

___cutting behavior
___disabling physical/mental illness in guardian/parent

Patient’s signature/Parent/Legal guardian signature


Signature of therapist


Signature of supervisor Date

Full Circle Behavioral Health, PC.
West Bloomfield,

Contact Lori Little, MA, Psychotherapist to answer any questions, for a Free and confidential phone consultation, or to make an appointment at (248)722-2653 or Contact Us To return to Home Page