Adult information form
Fill in all applicable fields
Present Problems and Conerns
Have you ever had thoughts, made statements, or attempted to hurt yourself?
Have you ever had thoughts, made statements, or attempted to hurt someone else?
Have you recently been physically hurt or threatened by someone else?
Family And Developmental History
Previous Mental Health Treatment
Substance Use History
Have you had withdrawl symptoms when trying to stop using any substances? If yes, please describe:
Have you ever had problems with work, relationships, health, the law, etc, due to your substance use? If yes, please describe:
Date of last physical exam:
List of any CURRENT HEALTH CONCERNS:
Current over-the-counter medications (including vitamins, herbal remedies, etc):
Have you ever had allergies and/or adverse reactions to medications:
If yes, please list:
Please describe your social support network (check all that apply):
If you are experiencing any diffculties due to cultural or ethnic issues, please describe:
How important are spiritual matters to you?
Would you like spiritual/religious beliefs to be incorporated into your counseling?
Please describe your strengths, skills, and talents:
Describe any special areas of interest or hobbies (art, books, physical fitness, etc):
Length of time:
Stress level of position:
Other jobs you have held:
Are you currently attending school?