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Psychotherapy Intake Application

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Psychotherapy Intake Application Powered By Docstoc
					Christine K. Joo, MA, LMHC
Christine Joo Psychotherapy
            Psychotherapy  Psychological Evaluation  Play Therapy for Adults  Adolescents  Children  Families  Couples

                  2018 156th Ave NE, Suite 241, Bellevue, WA 98007           Phone: 425-922-6783



                                Psychological Services Intake Information
                              Please fill out all information as completely as possible.

                                                                                               Date: ____________________

Name ________________________________________________________________________
                 Last                  First          Middle Initial
                 Maiden, if applicable
Address_______________________________________________________________________
                 Street                      Apt. No.     City        Zip Code

__________________                _________________                                     Female           Male
     Home Phone                       Work Phone

Date of Birth:                                                     Social Security #:

CHILDREN / STEPCHILDREN
                   Age  At home?                                                                           Age         At home?
First   ______________             _____           Yes          No       Fourth ___________                _____               Yes   No
Second ______________ _____                        Yes         No        Fifth       ___________           _____               Yes   No
Third ______________ _____                         Yes         No        Sixth      ___________           _____            Yes       No



OTHERS IN HOUSEHOLD
Name                                                                      Relationship                                           Age ______
Name                                                                      Relationship                                           Age ______

PRESENT MARITAL STATUS

   Single            Partnership               Married—Date of current marriage__________

   Separated/Divorced                 Widowed

PREVIOUS MARITAL STATUS

Applicant: Have you been married before?                                          No          Yes
Date(s) of marriage ____________________                                Date(s) of divorce/death ___________________

                                                                Joo 1
COUNSELING HISTORY

Have you ever had counseling before?        Yes            No   When: _________________________________

Please state briefly why you are seeking counseling services: _____________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Have you sought help for this particular concern before?
   No       Yes—When and where? ___________________________________________________________

__________________________________________________________________________________________________________


How would you assess the severity of this concern?           Mild      Moderate   Severe     Extreme

____________________________________________________________________________________
Have you ever experienced the following?
(Please indicate your rating on both current and past).
Use Number Rating Scale:
0 = none 1 = mild 2 = moderate         3 = severe         4 =extreme

                                Current    Past
Anxiety/Worries
Depression
Manic
Anger/ Agitation
Unwanted thoughts
Death of someone close to you
Suicidal thoughts
Suicide attempts
Homicidal thoughts
Other Mental illness
Sexual abuse
Physical abuse
Domestic Violence
Learning difficulties
Change in weight
Sleep difficulties
   Falling asleep
   Staying asleep
   Waking early
    Nightmares
Difficulty with concentration
                                                  Joo 2
Drinking problem
Drug use
Stomach pains
Headaches
Chest pains/ heart disease
Breathing problem
High or Low blood pressure
Diabetes
Cancer
Epilepsy
Irregular Menses
Constipation or Diarrhea
Child Birth Difficulty
Thyroid (hypo & hyper)
Other—please specify:




Please list any prescription medications you are presently taking.
Medication                          Dosage                           Purpose




Have you seen a doctor in the last year for any serious medical concerns? No  Yes-
Please explain _____________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Have you ever been hospitalized for psychiatric reasons? No
   Yes—Please provide dates and diagnoses ____________________________________________________
_________________________________________________________________________________________

Does anyone in your family have any mental disorder (diagnosed or suspected) or emotional
issues, including suicide?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________


Does anyone in your family have drug or alcohol issues?
____________________________________________________________________________________
____________________________________________________________________________________
                                               Joo 3
Does anyone (relative, friend, co-worker, supervisor) around you have a concern about your drug or
alcohol use?
   No

   Yes ___________________________________________________________________________________

Do you or have you ever had a concern about your alcohol or drug use?
                                   Yes      No

Which drugs have you or do you use? (specify type: e.g., prescription drugs, marijuana, alcohol,
cocaine, hallucinogen, other)



Who is your primary care physician & phone number? ____________________________________

____________________________________________________________________________________

When was your last physical examination? _____________________________________________


Who referred you to this office for services? ___________________________________________________


Thank you.




                                                Joo 4

				
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Description: Psychotherapy Intake Application document sample