Self Report Form

Name (First, M.I., Last)*

Street*

City*

State*

Zip Code*

Home Phone: *

Work Phone

Cell Phone

Email*

example@example.com

OK to contact via email?*

YesNo

Date of Birth*

Date

Preferred Gender*

Marital Status*

Employer*

School (if student)

Occupation*

Emergency Contact Name*

Emergency Contact Phone*

Relation to client*

Whom may we thank for referring you?

The following questions will help with serving you. Please read and answer each question carefully.

Ethnic/Cultural Identity: We recognize that the federal racial categories are limiting. Please write below whatever terms or phrases you find most descriptive of your ethnic or cultural identity or identities.

Do you identify with any religious and/or spiritual practices? If so, please describe.

Mental Health History

Why are you seeking treatment*

Have you ever been hospitalized for psychiatric issues or chemical dependence?*

YesNo

If yes, please list below the diagnosis, when, where, and by whom.

Have you ever been treated by a psychiatrist, therapist, EAP, or other clinician?*

YesNo

If yes, please list below the diagnosis, when, where, and by whom.

If applicable, please list below any traumatic or extremely upsetting events that might have occurred in your life.*

Are you experiencing any of the following:

Depression*

YesNo

Loss of interest in activities*

YesNo

Significant weight loss or gain*

YesNo

Increase or decrease in sleep*

YesNo

Increase or decrease in energy level*

YesNo

Feelings of worthlessness or guilt*

YesNo

Problems in concentration or decision making*

YesNo

Thoughts about death, suicide, or self-harm:*

YesNo

Anxiety*

YesNo

Panic or anxiety attacks*

YesNo

Fears*

YesNo

Nightmares*

YesNo

Eating in excess*

YesNo

Decrease in appetite*

YesNo

Concerns about body image*

YesNo

Persistent unpleasant thoughts*

YesNo

Times when you engage in repetitive behaviors*

YesNo

Worries about physical health, finances, other:*

YesNo

Have you ever experienced any of the following:

Periods of at least 4 days when you were so happy or excited you got into trouble or others became worried about you?*

YesNo

Periods of at least 4 days of irritability or temper problems?*

YesNo

Racing thoughts or an inability to keep up with your thoughts?*

YesNo

Hallucinations (i.e. seeing, hearing, or feeling something others cannot?*

YesNo

Thoughts that others are "out to get you?"*

YesNo

Memory problems?*

YesNo

Substance Use/Abuse History

How many times during the month do you consume alcohol?*

How much do you drink each time?

Do you use any illegal drugs (Marijuana, Cocaine, Amphetamines, Heroin, other)?*

YesNo

If yes, please list below or indicate if you would prefer for your therapist to ask about this in session.

Have you used any illegal drugs in the past?*

YesNo

If yes, please list below or indicate if you would prefer for your therapist to ask about this in session.

Have you ever abused prescription medications or over-the-counter medications such as pain medications, narcotics, anxiety medications, tranquilizers, or sleeping medications?*

YesNo

If yes, please list below, and time of last use.

Have you ever participated in NA/AA or other self-help programs?*

YesNo

If yes, please describe your experience.

How many caffeine products (soda, coffee, energy drinks) do you consume each day?*

Do you use tobacco products?*

YesNo

If yes, please describe below what you use and how much.

Family History

Is there any family history of any of the following:

High blood pressure*

YesNo

Heart disease*

YesNo

Diabetes*

YesNo

Seizures*

YesNo

Cancer*

YesNo

Alzheimer's*

YesNo

Is there any family history of mental conditions or chemical dependence such as:

Depression*

YesNo

Attention deficit*

YesNo

Bipolar disorder*

YesNo

Anxiety disorders*

YesNo

Schizophrenia*

YesNo

Alcoholism*

YesNo

Mental Disabilities*

YesNo

Drug addiction*

YesNo

Learning problems*

YesNo

Suicides/attempts*

YesNo

Other (please describe)

Medical History and Medications

Please list any current medical problems and the name of your treating physician*

Please list all current psychiatric medications/Dose/Reason for taking:*

Please list all other current medications including prescription and over the counter as well as the dosage and reason:*

Please list all past psychiatric medications:*

Are you allergic to any medications?*

YesNo

If yes, please list below

Have you ever experienced head trauma with loss of consciousness?*

YesNo

Have you ever experienced seizures?*

YesNo

If you are a woman, are you pregnant or plan to be?*

YesNoUnsure

Have you ever been hospitalized for major surgeries or illness?*

YesNo

If yes, please list below the diagnosis, when, where, and by whom.

What do you hope to achieve from therapy?*

Please list any specific requests or anything else that I should know about you to help make your treatment experience more successful?*