Instructions: Your therapist would like each adult in the family to answer these questions. This will help him or her better understand your situation and problems.

Names of all who reside in household:


In case of an emergency, name and telephone number of your nearest relative:

___________________________________________________ Telephone:____________________

Who referred you?/How did you hear about us?


PSYCHOLOGICAL HISTORY

A. What problem(s) caused you to seek help?


B. Check if you have had any of these problems or symptoms recently:

___ Fears (circle):     dying    going crazy   crowds    public speaking
         other:______________

C. Have there been any recent illnesses or deaths among your family or close friends?
      ___ Yes ___ No
D. Have there been any recent crises or major changes in your life?
      ___ Yes ___ No
E. Have you ever experienced any emotional, physical, or sexual abuse?
      ___ Yes ___ No
F. Have you ever intentionally hurt yourself or made a suicide attempt?
      ___ Yes ___ No
G. List any medications for anxiety, depression, sleep, or emotional conditions that you have taken now or in the past. List them:


H. Have you been in counseling or psychotherapy or had treatment from a psychiatrist before?
     ___ Yes ___ No
When and with whom:


I. Have you had any hospitalization(s) for emotional problems?
    ___ Yes ___ No
When and where:


J. Please name any people or organizations that provide help and support to your family:


MEDICAL HISTORY

A. List any current medical conditions and disabilities:


B. List ANY medications you are taking for any medical conditions.


C. List past medical conditions (include any surgeries):


D. Name of your physician(s) and their telephone number(s) and address(es):


E. Have you had a medical exam within the past year?
      __ Yes ___ No
Findings:


F. Indicate anyone in the family who has had these problems:

DRUG AND ALCOHOL USE

A. Please describe the drug and alcohol use of your family. Use the number which best states how often each person uses each drug. For your children, please write in the name of the child at the top of the column. If the use is a problem, circle the number you enter.

0 = Never, 1 = less than once a month, 2 =weekends only, 4 = 10 or more days a month,
5 = daily or almost daily, 6 = used in past, not using now.
If you view this pattern as a problem, circle the number.

B. Are you concerned about your drug or alcohol use?
     ___ Yes ___ No
C. Is someone who cares about you concerned about your use of drugs or alcohol?
     ___ Yes ___ No
D. Do you get angry when others criticize your use of drugs or alcohol?
     ___ Yes ___ No
E. Do you ever feel guilty about your use of drugs or alcohol?
     ___ Yes ___ No
F. Are you concerned about the drug or alcohol use of someone in your family?
     ___ Yes ___ No
G. Did you grow up in a home in which a parent abused drugs or alcohol?
     ___ Yes ___ No
H. Age at first drink? ______________________ Age of first use of other drugs?_________
I. Which of these reasons for drinking apply to you?
(circle)   Relieve stress   Escape pain   Lower inhibitions   To be sociable   To go along with others
               To get high   Like the taste   Reduce tension before flying or meetings   Relaxation   Other:

LEGAL PROBLEMS

A. Have you ever been arrested (including OWI/DUI)?
     ___ Yes ___ No
B. Have you ever been involved with Protective Services?
     ___ Yes ___ No
C. Please list other legal problems:

SCHOOL AND WORK HISTORY

A. Are you currently enrolled in school?
     ___ Yes ___ No
B. Highest grade completed? __________________________
C. If you are in school, what field are you studying and which school?_____________________________
D. Your occupation(s):__________________________________
E. Length of time at current job? _____________

What strengths do you feel will enable you to help resolve problems you may have:

rev 5/25/06