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Paramount Recovery & Addiction Application for Services
Date ___________________________ |
| Your name |
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| Home phone |
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| Business phone |
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| Is it okay to leave a message if you do not answer? |
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| E-mail address |
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| Address |
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| Family member to be contacted in case of an emergency |
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| Family member's phone |
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| Family member's address |
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| Your age |
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| Your date of birth |
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| Social Security Number |
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| How did you find out about my office? |
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| What type of work do you do? |
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| Your employer |
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| How many years of education have you completed? |
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History |
Have you had previous therapy?
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Name of Therapist |
Dates |
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Reasons |
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| Was this therapy a positive experience? |
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| Was medication prescribed? If so, what? |
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| Was the medication effective? |
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| If you are currently on any type of medication, please list it here with dosage and length of time you have taken it. (Many affect mental health.) |
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| List any health problems. |
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Your current doctor |
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| Current doctor's phone |
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Please mark any of the following problems you are experiencing.
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Academic |
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Financial problems |
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Sexual assault/incest |
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Anxiety/stress disorder |
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Gender role issues |
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Physical abuse |
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Business/work related |
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Marital/partner problems |
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Sexual functioning |
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Drug/alcohol |
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Medical problems |
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Social skills |
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Eating disorder |
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Mood disorder - depression, etc. |
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Legal |
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Family problems |
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Problems with your children |
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Other |
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| How long have you been experiencing the current problems? |
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| Please briefly describe your current problem(s) in your own words. Use last page of this form for more space if necessary. |
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Family |
| List the people you consider to be your family members. Please put a check mark in front of the names of those who live in your current home. |
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Additional family members not in your current home
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| If you have experienced a family divorce, how old were you? |
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| If the divorce happened to you as a child, how old were you when your parents remarried? |
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| Who are the other important persons in your life? (First name and relationship.) |
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YES |
NO |
COMMENTS |
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Have you been in the military? |
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Dates: |
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Are you are sexual assault/incest survivor? |
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Is there physical/emotional violence in your family? |
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Have you been physically abused? |
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Have you ever been arrested? |
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| Do you have problems with anger? |
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| Is there a family history of alcohol/drug abuse? |
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| Is there a family history of mental illness? |
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| Do you cut, burn, mark yourself? |
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| Have you ever had an eating disorder? |
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| Have you been hospitalized for medical/emotional problems? |
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| Do you tend to have intense relationships where you alternate between feelings of trust and betrayal/anger? |
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| Do you have any serious medical problems? (Many affect mental health.) |
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What are two or three major things that have happened to you that are important to the way that you think about yourself?
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Present Situation |
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What is your living situation currently? (Family home, roommate, etc.)?
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How many hours per week are you employed? _____ In school? _____ What other major time commitments do you have?
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What are some of your personal strengths?
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If therapy accomplishes what you want, what will be different in your life at the end of therapy?
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If religion or a particular philosophy is important to you in ways that might influence your counseling, please comment.
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Can you make the commitment to bring up the issue of suicide if (or when) it is an active part of your thinking? _____ Have you had any thoughts of suicide in the last month? _____ |
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Please answer the following questions.
| PLEASE ANSWER THE FOLLOWING QUESTIONS |
STRONG OR GOOD ------------------------>PROBLEMATIC |
| How satisfactory is your current living situation? |
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| How satisfactory is your relationship with your family? |
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| How do you feel about your social skills? |
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| How good do you feel about your body image? |
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| How connected do you feel with friends and others? |
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| How optimistic do you feel about the future? |
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| How do you feel about your sexuality? |
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| How satisfactory is your work situation? |
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| In the most recent month, approximately how many days did you take medicine? _____ Drink alcohol? _____ Smoke? _____ Use drugs to alter your mood or sociability? _____ Binge on sugar? _____ Binge eat? _____ Drink too much caffeine for you? _____ Vomit? _____ Gamble? _____ |
| Have you ever had a drug or alcohol problem? _____ Eating disorder? _____ |
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