BIOPSYCHOSOCIAL FORM

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.
NAME:
TELEPHONE:
DATE:

MonthDayYear
Date
ADDRESS:
EMAIL
example@example.com
PHYSICAL FEATURES
Date of Birth:

MonthDayYear
Date
Age:
Where were you born:
When did you come to FL:
Height:
Weight:
Eye Color:
Hair Color:
Number of Children:
Religion:
How does your religion influence your life
HEALTH INFORMATION
When were you last seen by your primary doctor?
Are you worried about your health?
If so, about what?
Do you have any long term illnesses, injuries or disabilities?
If so, what are they?
List any medication you take:
Have you ever been in therapy before?

YesNo
If yes, please explain:
Describe your health. (Choose one)

ExcellentGoodFairPoor
Have you ever tried to commit suicide?

YesNo
If yes, please explain:
RISK ASSESMENT
Over the past two weeks, how often have you experienced the following?
Little interest or pleasure in doing things

NeverSeveral DaysMore than 1/2 timeMost Days
Feeling down, depressed, or hopeless

NeverSeveral DaysMore than 1/2 timeMost Days
Feeling bad about yourself

NeverSeveral DaysMore than 1/2 timeMost Days
Have had thoughts about killing yourself

NeverSeveral DaysMore than 1/2 timeMost Days
Have you planned how you might kill yourself

NeverSeveral DaysMore than 1/2 timeMost Days
HIV/HEPATITIS B RISK ASSESMENT
Please read each of the following question and check for any “yes” answers

Used a needle to take drugsShared needles with anyoneEngaged in sex in jail/prisonAny blood transfusion from 1977-1986Exchanged money or drugs for sexEver had Herpes, Hepatitis or VDBeen in jail or prison(Men only) Had male to male sexHad more than one sex partner in the last yearForgot what you did when you were highEngaged in sex or shared needles with someone who is HIV/AIDS positiveHad sex with anyone who would anser yes to any above questions
Date of your last HIV/Hepatitis Test
Date

MonthDayYear
Date
Referral required:

YesNo
Referred to:

Care ResourcesBroward House
Client Signature

Clear
Date

MonthDayYear
Date
PAIN ASSESMENT
Select the level of pain you are experiencing

No HurtHurts Little BitHurts Little MoreHurts Even MoreHurts Whole LotHurts Worst
Nutritional History
How would you generally describe your eating habits?

GoodFairPoor
Has your appetite changed lately?

YesNo
Do you eat breakfast?

YesNo
Do you eat lunch?

YesNo
Do you eat dinner?

YesNo
Do you eat snacks?

YesNo
4. How long does it usually take to complete a meal (in minutes)?
5. Number of carbonated beverages daily
6. Number of caffeinated beverages daily (coffee, regular colas, tea)
number of servings of cola daily (regular, diet)
7. Do you take any vitamins or minerals?

YesNo
If you answered yes, please list the vitamins or minerals you take
8. List any foods that you do NOT tolerate:
9. Are you now on any special diet

YesNo
If yes, what type of diet?
How many times per week do you eat out?
What type of restaurants to you go to?
FAMILY HISTORY
Culture and Ethnicity (Select One)

AfricanAfrican AmericanNative AmericanAsianBi-RacialCaucasian
How does culture influence your life?
Select ways your family supports you:

FinanciallyEmotionallyHousingChildcare
What type of housing do you live in?

HouseApartmentCondo1/2 Way HouseHomeless Shelter
Select your living conditions

ExcellentGoodFairPoor
How many people live in your home?
Who handles the household chores?
Who pays the household financial obligations?
If you have children, do they live with you?

YesNo
List their names and ages:
How many siblings do you have:
How often do you get together?
Who are you closest to:
Father's Name:
Father's occupation when you were growing up:
Where was he born:
His age:
If deceased, how old were you when he died:
Mother's Name:
Her occupation while you were growing up:
Where was she born:
Her age:
If deceased, how old were you when she died:
PLEASE FINISH THE FOLLOWING:
In my growing up years my parents argued
In my growing up years my parents showed their affection to each other by
In your growing up years did you witness any domestic violence?

YesNo
If yes, explain:
If so, who?
In your growing up years did either of your parents suffer from alcoholism/drug abuse, violence, criminal behavior, sexual problems or mental illness?

yesno
If so, who?
explain
Did your parents stay together during the time you were growing up?
If not, how old were you when they separated?
What was your father like when you were growing up?
How did he discipline you?
How did he show you affection and concern?
Client Name:
What was your mother like when you were growing up?
How did she discipline you?
How did she show you affection and concern?
Did you live with one or both of your parents while growing up?

YesNo
If not, who did you live with?
How did you feel about your parents when you were growing up?
Did you ever live in foster care?

YesNo
If so, check all that apply

PhysicalEmotionalSexual
If so, how many years
During what ages?
Were you ever abused while you were growing up?

YesNo
Trauma. If yes, explain
Who do you does the most good in your life?
Why?
Who do you hold at fault for the problems you have in life?
Why?
Most of my growing up years were (check those that appy):

HappyFunSadUnhappyCaringUneventfulViolent
Who are you closest to in the family?
Do any of your brothers / sisters suffer from drug / alcohol abuse, violent criminal behavior, sexual problems or mental illness?

YesNo
Who do you feel does the most good in your life?
If so, who? Explain:
CHILDHOOD AN ADOLESCENT HISTORY
Did you have any health problems as a child?

YesNo
If yes, describe:
Dis you have any frightening things happen to you as a child / adolescent (trauma)?

YesNo
If yes, describe:
Most of my growing up years were (circle those that apply)
Select any of the following that applied to you as a child or teenager:

WithdrawnDelinquentFriendlessShortLostUnlovedSocialUglyHappyAngryHomelessFatLovingAshamedTroubledAttractiveSuicidalNeglectedSmartAthleticPlayfulMolestedStrongFollowerLovedLonelySkinnyBulliedLeaderAbusedRunawayPopularShySlowClownEmotionally DisturbedKindBrightSeizuresMeanBullyTall
In school, my average grades were (select one)

ABCDF
Did you study?
Did you do homework?
Did you skip class
If so, what did you do instead of going to class?
Why?
Were you ever expelled from school?

YesNo
If so, why?
What activities, including sports, did you participate in school?
Did you take:

easy coursesgeneral coursesvocational coursescollege prep classes
What was the highest grade you attended?
Did you graduate?
Did you get your GED?
What was you GPA?
Did you attend vocational school?
If so, what did you study?
Did you complete Vocational School?
Did you attend college?
If so, what was your major?
What is your highest degree?
ARMED FORCES SERVICE HISTORY
Branch
Length of time served
Type of discharge
WORK HISTORY
My major trade, craft, profession or occupation is:
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
Job 1
Job 2
Job 3
Have you ever been fired from a job?
If so, why?
Client name:
ADULT BEHAVIORAL HISTORY
Check any of the following behaviors that apply to you since you turned 16:

Breaking and enteringSex devianceMuggingDisorderly conductProbation violationTrespassingNegligent drivingVandalismFightingWriting Bad ChecksCruelty to AnimalsShoplifitingDomestic violenceAssault/BatteryLoiteringAlcohol / drug abuseDUI/DWIBurglaryAuto theftChild abuse / neglectTraffic violations
ARREST HISTORY
List all arrests and punishments since you were 18:

Consequences (jail, probation, community service, diversion program, etc
Arrest #1
Arrest #2
Arrest #3
Arrest #4
Check any of the following problems you have or things that you worry about:

Money problemsHealth problemsMental problemsAlcohol problemsDrug problemsLearning problemsMemory problemsFamily problemsFriendship problemsPanic problemsAnger problemsSexual problemsLooks problemsViolence problems
Please explain the above problem(s)
Check the feeling that you feel most of the time:

AngerGuiltFearSadnessShameHappinessJoyPowerHurt
FRIENDSHIPS AND SOCIAL ACTIVITIES
How many close friends do you have?
What social activities do you and your friend engage in?
Comments on any issue above:
SUBSTANCE (DRUG/ALCOHOL) HISTORY
I first tried drinking alcohol at age
I had my last drink on:
My usual alcoholic drink is:
I drink alcohol (check the one that fits you best):
weekendsdailyonce a week3-4 times a weekNever
I usually drink (check all that fit you):

By myselfwith friendsAt partiesAt homeAt schoolAt games
Do you think you have a problem with alcohol?

YesNo
Has anyone ever told you that you have an alcohol problem?

YesNo
I first used drugs at the age of :
I have tried the follow kinds of drugs (please check all you have tried):

MarijuanaHeroinCocaineCrackOpioidsPCPAmphetamineMethLSDSpiceBarbituratesXanaxValiumBenzosHashishTobaccoMushroomsFlakkaFentanyl
Others:
Have you been in a drug/alcohol treatment program(s)?

YesNo
If yes, how long did you stay clean and sober?
Client Name
THE MAST TEST
Do you feel you are a normal drinker/drug user?

YesNo
Have you ever awakened the morning after drinking/drug use the night before and found that you could not remember a part of the evening?

YesNo
Does any near relative or close friend ever worry or complain about your drinking/drug use

YesNo
Can you stop drinking using drug without difficulty after one or two drinks/drugs?

YesNo
Do you ever feel guilty about your drinking or other drug use?

YesNo
Have you ever attended a meeting of Alcoholics Anonymous(AA) or Narcotics Anonymous?

YesNo
Have you ever gotten into physical fights when drinking or using other drugs

YesNo
Has drinking or drug use ever created problems between you and a relative or close friend?

YesNo
Has any family member or close friend gone to anyone for help about your drinking /drugs?

YesNo
Have you ever lost friends because of your drinking or other drug use?

YesNo
Have you ever gotten into trouble at work because of drinking or using drugs?

YesNo
Have you ever lost a job because of drinking or drug use?

YesNo
Have you ever neglected your obligations, family, or work for two or more days in a row because you were drinking or using other drugs?

YesNo
Do you drink or use drugs before noon fairly often?

YesNo
Have you ever been told you have liver trouble, such as cirrhosis?

YesNo
After drinking or using drugs, have you ever had delirium tremens (DTs), severe shaking, visual or auditory (hearing) hallucinations?

YesNo
Have you ever gone to anyone for help about your drinking or drug use?

YesNo
Have you ever been hospitalized because of drinking or drug use?

YesNo
Has your drinking or drug use ever resulted in your being hospitalized in a psychiatric ward?

YesNo
Have you ever gone to any doctor, social worker, clergyman, or mental health clinic for help with any emotional problem in which drinking or drug use was part of the problem?

YesNo
Have you been arrested for driving under the influence of alcohol or other drugs.

YesNo
Have you ever been arrested, or detained by an official for a few hours, because of other behaviors while drinking or using other drugs

YesNo
Client Name:
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.
Client Signature

Clear
Date

MonthDayYear
Date
Parent / Guardian Signature

Clear
Date

MonthDayYear
Date
CONSENT TO RELEASE OR EXCHANGE INFORMATION
Your name
Birth Date:

MonthDayYear
Date
SS#
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:
Name
Phone
Email
example@example.com
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.
(initials)
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.
(initials)
If you are under the supervision of the Department of Corrections, I understand that the Department of Corrections hasaccess to all program information and alcohol and drug screening and testing results.
Initial Here
Client (or Guardian) Signature

Clear
Date

MonthDayYear
Date
Beck's Depression Inventory
NAME:
DATE:

MonthDayYear
Date
(Please select the most appropriate answer in each category)
Select one

I do not feel sad.I feel sadI am sad all the time and I can't snap out of it.I am so sad and unhappy that I can't stand it.
Select one

I am not particularly discouraged about the future.I feel discouraged about the future.I feel I have nothing to look forward to.I feel the future is hopeless and that things cannot improve.
Select one

I do not feel like a failure.I feel I have failed more than the average person.As I look back on my life, all I can see is a lot of failures.I feel I am a complete failure as a person.
Select one

I get as much satisfaction out of things as I used to.I don't enjoy things the way I used to.I don't get real satisfaction out of anything anymore.I am dissatisfied or bored with everything.
Select one

I don't feel particularly guiltyI feel guilty a good part of the time.I feel quite guilty most of the time.I feel guilty all of the time.
Select one

I don't feel I am being punished.I feel I may be punished.I expect to be punished.I feel I am being punished.
Select one

I don't feel disappointed in myself.I am disappointed in myself.I am disgusted with myself.I hate myself.
Select one

I don't feel I am any worse than anybody else.I am critical of myself for my weaknesses or mistakes.I blame myself all the time for my faults.I blame myself for everything bad that happens.
Select one

I don't have any thoughts of killing myself.I have thoughts of killing myself, but I would not carry them out.I would like to kill myselfI would kill myself if I had the chance.
Select one

I don't cry any more than usual.I cry more now than I used to.I cry all the time now.I used to be able to cry, but now I can't cry even though I want to.
Select one

I am no more irritated by things than I ever was.I am slightly more irritated now than usual.I am quite annoyed or irritated a good deal of the time.I feel irritated all the time.
Select one

I have not lost interest in other people.I am less interested in other people than I used to be.I have lost most of my interest in other people.I have lost all of my interest in other people.
Select one

I make decisions about as well as I ever could.I put off making decisions more than I used to.I have greater difficulty in making decisions more than I used to.I can't make decisions at all anymore.
Select one

I don't feel that I look any worse than I used to.I feel there are permanent changes in my appearance that make me look unattractiveI believe that I look ugly.
Select one

I can work about as well as before.It takes an extra effort to get started at doing something.I have to push myself very hard to do anything.I can't do any work at all.
Select one

I can sleep as well as usual.I don't sleep as well as I used to.I wake up 1-2 hours earlier than usual and find it hard to get back to sleep.I wake up several hours earlier than I used to and cannot get back to sleep.
Select one

I don't get more tired than usual.I get tired more easily than I used to.I get tired from doing almost anything.I am too tired to do anything.
Select one

My appetite is no worse than usual.My appetite is not as good as it used to be.My appetite is much worse now.I have no appetite at all anymore.
Select one

I haven't lost much weight, if any, lately.I have lost more than five pounds.I have lost more than ten pounds.I have lost more than fifteen pounds.
Select one

I am no more worried about my health than usual.I am worried about physical problems like aches, pains, upset stomach, or constipation.I am very worried about physical problems and it's hard to think of much else.I am so worried about my physical problems that I cannot think of anything else.
Select one

I have not noticed any recent change in my interest in sex.I am less interested in sex than I used to be.I have almost no interest in sex.I have lost interest in sex completely.
Should be Empty:

PHYSICAL FEATURES

HEALTH INFORMATION

RISK ASSESMENT

HIV/HEPATITIS B RISK ASSESMENT

PAIN ASSESMENT

Nutritional History

FAMILY HISTORY

PLEASE FINISH THE FOLLOWING:

CHILDHOOD AN ADOLESCENT HISTORY

ARMED FORCES SERVICE HISTORY

WORK HISTORY

ADULT BEHAVIORAL HISTORY

ARREST HISTORY

FRIENDSHIPS AND SOCIAL ACTIVITIES

SUBSTANCE (DRUG/ALCOHOL) HISTORY

THE MAST TEST

THERAPY AGREEMENT

CONSENT TO RELEASE OR EXCHANGE INFORMATION

Beck's Depression Inventory