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: _____________________________________________
SS#_________________________Date____________________________

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: ______
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? ________________________________

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? _________________________________

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

Education
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: _____________________________________________________________________

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

Duty: ___________________ Rank: ______________________ Honorable discharge? _____________

Legal
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: _____________________________________________________________________

Recreation/Socialization
How would you describe your friendships?____________________________

Describe your typical daily activities: ______________________________________________________________________

What activities do you enjoy ? ___________________________________________________________

What recreational activities do you participate? _____________________________________________

Financial
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
___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

___________________________________________________________
Signature of supervisor Date

Full Circle Behavioral Health, PC.
West Bloomfield,
(248)722-2653

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


Home Contact Us New clients Anxiety Causes of Anxiety Anxiety, What is it? Anxiety Therapy Depression depression, what is it? RelationshipTherapy Substance Abuse ADHD Wellness Services Our Mission About Recommended Reading Subscribe to E-Zine Insurance Accepted Payments Auto Trauma	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: _____________________________________________ SS#_________________________Date____________________________ 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: ______ 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? ________________________________ 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? _________________________________ 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 all past and significant relationships/marriages: age, duration, # of children, and name of significant other, ______________________ __________________________________________________________________ Education 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: _____________________________________________________________________ Military Have you been in the armed forces?_____ If yes, when? _____________ Branch __________________ Duty: ___________________ Rank: ______________________ Honorable discharge? _____________ Legal 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: _____________________________________________________________________ Recreation/Socialization How would you describe your friendships?____________________________ Describe your typical daily activities: ______________________________________________________________________ What activities do you enjoy ? ___________________________________________________________ What recreational activities do you participate? _____________________________________________ Financial 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 ___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 ___________________________________________________________ Signature of supervisor Date Full Circle Behavioral Health, PC. West Bloomfield, (248)722-2653 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