Background Background Information This form can be used to provide useful information prior to your first visit. All of the sections are optional. Feel free to be as detailed as you like. You may skip any question. For questions that ask you to list something click on the "+" icon to add another line. Date MM slash DD slash YYYY Name First Last Age In one or two sentences why have you sought treatment? How long has this been going on? Are any of these problems you would like to address in therapy? Depression Anxiety Anger Issues Traumatic Experiences Relationship/Family issues Stress Management Work-related issues Mood swings Beck Depression Inventory - II Sadness Actions Edit Delete There are no Entries. Add Symptoms of Depression Maximum number of entries reached. Because you check depression as something you would like to address in therapy please complete this more detailed rating scale to tell us more about your symptoms. Click on the "Add Symptoms of Depression" to make your ratings. When done you can return to complete the rest of the Background Information Form. Beck Anxiety Inventory Unable to relax Actions Edit Delete There are no Entries. Add Symptoms of Anxiety Maximum number of entries reached. Because you check anxiety as something you would like to address in therapy please complete this more detailed rating scale to tell us more about your symptoms. Click on the "Add Symptoms of Anxiety" to make your ratings. When done you can return to complete the rest of the Background Information Form. Any special reason why you choose to seek therapy at this time? List any major stressors you have experienced during the last year. (check all that apply) Death of a loved one Divorce Marital separation Major personal injury or illness Marriage Loss of job Retirement Financial problems Moving into new house Taking care of elderly or sick family member Traumatic event such as natural disaster or violence against you or family member Pregnancy Sexual difficulties Changing jobs If you have experienced any significant stressors offer any details you'd like here. Have you ever met with a mental health professional before? Yes No Prior Treatment Inpatient Outpatient Psychotherapy Medication Only List prior treatment experiences (Name, approximate dates) Professional’s name Date Approximate number sessions Prior Treatment Please describe a little about your prior treatment. What did you like most from your prior treatment? What did you like least? What was the general approach of the treatment? Are you on any medications? Yes No Please list medications. Include dose and reason for taking. Click on the "+" icon to add another line. Name of Medication Dose Reason for taking Have you experienced any significant illnesses or injuries? Yes No Briefly describe illnesses or injuries. Include dates if relevant. Click on the "+" icon to add another line. Has your use of alcohol or drugs ever been a problem for you? Yes No What substance was/is a problem for you? alcohol drugs prescription medications What drugs you have used. Include name, last time used, and describe use last 3 months or so. Click on the "+" icon to add another line. Name Date of last use Use during last few months Please list the medications you have had a problem with. click on the "+" icon to add another line. What age did you begin drinking? What age did you first notice your drinking was a problem? Describe your current use of alcohol. Describe amounts, context you usually drink, and anything you think would be useful to include. Have you ever been arrested? Yes No Have you ever served in the military? Yes No Provide any details you think would be helpful. Please describe your service. How far did you go in school? Grade School GED High School Some College College Degree Graduate Degree Name of Institution / Field of study / Year Name of Institution Field of study Dates attended Describe what you do for a living, any previous work, any issues that are work-related. Marital Status (choose all that apply) Married Separated Divorced Single, live with partner Single, live alone Not currently in a relationship What is your spouse's/partner's name? Name/Age of Spouse or Partner Partner's Name Age Do you have children? Yes No Name of Child / Age (Click on the "+" icon to add another line.) Do you have brothers or sisters? or step siblings? Yes No Name of Siblings / approximate age (click on the "+" icon to add another line.) Describe your family growing up. What did you like most? What aspect would you have changed? Did you experience any abuse as a child? (check all that apply) No Not sure Yes, physical abuse Yes, sexual abuse Yes, emotional abuse Describe your experience with physical abuse providing whatever details you feel comfortable sharing? Describe your experience with emotional abuse providing whatever details you feel comfortable sharing? Describe your experience with sexual abuse if you feel comfortable sharing details. Who was the perpetrator(s), what age did it begin, what age did it stop, why did it stop, did you ever tell anyone, if you did what was the response? Have you experienced any traumatic stressors? Yes No Please explain any traumatic events you have experienced. How would you describe your sleep patterns? I sleep well I have trouble falling asleep I wake up in the middle of the night for long periods. I wake up early in the morning and can't go back to sleep My wake time varies quite a bit I sleep more than is usual for me and am still tired. How would you describe your appetite? I have a good appetite. No changes. I have less appetite than usual. I have almost no appetite. I eat more than is usual for me. My eating habits are healthy. I have fairly poor eating habits. Have you ever struggled with thoughts of suicide? Yes No When have you struggled with these thoughts? In the past Currently Do you ever question whether you would act on these thoughts? No, I've never thought I would actually act on them. Yes, sometimes. What do you do for fun? How do you spend your leisure time? Do you have any hobbies? Describe your goals for treatment. What do you want to change? How will things look if you make the changes you want to make? Feel free to use this section to upload any file you would like your doctor to review prior to first visit. Things like past records or evaluations or any type of document that is relevant to your therapy. Max. file size: 100 MB. If you are satisfied with your answers hit the "Submit" button.
