• FIFTH STREET COUNSELING IV, INC. BIOPYCHOSOCIAL LIFE HISTORY

    PURPOSE: the purpose of this history inventory is to get a picture of your life history as seen through your eyes and experience. It is assumed that you know the most about yourself and your life, since you have been the only person to have lived it. You will find that some questions take a little time and thought, but answering the questions fully will help us to understand you better.

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  • PHYSICAL FEATURES

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  • HEALTH INFORMATION

  • RISK ASSESMENT

  • Over the past two weeks, how often have you experienced the following?
  • HIV/HEPATITIS B RISK ASSESMENT

  • Date of your last HIV/Hepatitis Test

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  • PAIN ASSESMENT

  • Nutritional History

  • FAMILY HISTORY




  • PLEASE FINISH THE FOLLOWING:

  • Who do you feel does the most good in your life? 

  • CHILDHOOD AN ADOLESCENT HISTORY

  • Most of my growing up years were (circle those that apply)

  • ARMED FORCES SERVICE HISTORY

  • WORK HISTORY

  • List your jobs for the last 5 years (beginning with your present job):

    Please list type of work, company, reason for leaving and length of time for each job

  • ADULT BEHAVIORAL HISTORY

  • ARREST HISTORY

  • List all arrests and punishments since you were 18:

    Consequences (jail, probation, community service, diversion program, etc

  • FRIENDSHIPS AND SOCIAL ACTIVITIES

  • SUBSTANCE (DRUG/ALCOHOL) HISTORY

  • I drink alcohol (check the one that fits you best):

  • THE MAST TEST

  • THERAPY AGREEMENT

  • I (We) understand that the counseling services are strictly confidential with the following exceptions.

    • A legitimate subpoena by a court of law requires the release of information specified by the subpoena,
    • Statement of intent to harm oneself or another may result in notification of the intended victim(s) and appropriate

    • Information regarding suspected child of elderly abuse or neglect must be reported as mandated by Florida Statute

    • Information regarding treatment of a minor without parental consent may be shares with the parent(s), legal

    guardian(s), or legal authorities All information concerning other clients of FIFTH STREET COUNSELING IV, is to be held strictly confidential.

    I understand that counselors are not available 24 hours a day and that in a crisis situation the Crisis Line is available for community use. All payments for service rendered is due at the time service is provided. A returned check charge of $35 will be imposed for NSF checks. There are additional charges for letters, court or court-related appearances. Cancellation of a scheduled appointment must be made at l ease 24 HOURS IN ADVANCE of the appointment, or there will be a charge for the missed appointment.

    Fees for services are as follows:

  • Additional fees (telephone calls. Letters reports, evaluation, etc may be charged and will be discussed with you in therapy.

    I (We) understand and agree to the above conditions.

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  • CONSENT TO RELEASE OR EXCHANGE INFORMATION

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  • I understand that my records are protected under the Federal regulations that govern confidentiality and Drug Abuse Patient Records, 42 CFR Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand that I may revoke this consent at any time except to the extent that actions have been taken in reliance on it, and that in any event, this consent requires automatically one year from today. I hereby authorize and request Fifth Street Counseling Center IV, Inc. or it’s affiliates to release, receive or exchange information with:

  • I understand that I may revoke this consent at any time except to the extent that information has already been exchanged in reliance on this document.

  • I hereby release Fifth Street Counseling Center IV and the above named persons for all legal responsibility or liabilities that may arise from the exchange of this information. I waive my rights to confidentiality for any legal proceedings arising from this release or exchange of information. A copy of this document is available for my records on request.

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  • Beck's Depression Inventory

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  • (Please select the most appropriate answer in each category)

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  • Should be Empty: