Welcome New Clients!
Welcome to Full Circle Behavioral Health, PC., where we strive to enable those committed to themselves. 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: ___________________________________________SS#__________________Date__________ If a child, parent's names including step-parents: ________________________________________________________________________________ Address: _____________________________________ City: ____________________ Home Phone ( )______________Cell: ( )__________________ Bus. ( )______________ 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? __________________________________________________________________________________ Mother’s age: _____ Deceased, your age: _____Her age at your birth: ______ Occupation: __________Father’s age: _____ Deceased, your age: _____ His age at your birth: ______ Occupation:___________ 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? ________ Mother: _____________________________________________________________________________ Father: _____________________________________________________________________________ Brothers: ____________________________________________________________________________ Sisters: _____________________________________________________________________________ Stepmother: _________________________________________________________________________ Stepfather: __________________________________________________________________________ Stepsiblings: _________________________________________________________________________ Half siblings: ________________________________________________________________________ Grandparents: ________________________________________________________________________ Culture, Ethnicity, Spirituality, ReligionDescribe any cultural, ethical, or religious concerns that might influence your treatment: __________________________________________________________ Does spirituality influence your life? _____ Religious Preference: ___________________ Active? ____ Limitations Affecting Treatment Abuse History 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? _________________________________ Relationships: 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 the names and ages of your children and the name of other parent ___________________________ List all past and significant relationships/marriages: age, duration, # of children, and name of significant other, _______________________________ Are you currently involved in a long term relationship? If yes, duration, __________________________ EducationHighest 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? _______ Reasons for leaving: ___________________________________________________________________ MilitaryHave you been in the armed forces?_____ If yes, when? _____________ Branch __________________ Duty: ___________________ Rank: ______________________ Honorable discharge? _____________ LegalHave you ever been arrested? _____ If yes, please list all offenses, and result: _____________________ Do you have a pending case? _____ Are you seeking treatment for court? _______ Are you on probation/parole at this time? __________ If yes dates of term: _________________________________ Recreation/SocializationHow would you describe your friendships? _________________________________________________ Describe your typical daily activities: _____________________________________________________ What activities do you enjoy ? ___________________________________________________________ What recreational activities do you participate? _____________________________________________ FinancialDo you currently have financial problems? _____ Please explain: _______________________________ Treatment HistoryHave 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 HealthAre 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 UseDo 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: List medications are you currently taking and their doses: ___________________________________________________________________ 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___custody problems/issues ___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 _________________________________________ Date ____________________________________________________________ Signature of therapist __________________________________________ Date Full Circle Behavioral Health, PC.Farmington Hills, MI(248)722-2653Contact 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 |