Therapy Intake

Assessments
Qualitative Assessments

Clinical InterviewBehavioral Observations
Other Qualitative Assessments
Quantitative Assessments

Beck Anxiety InventoryBeck Depression InventoryPersonality Assessment Inventory
Other Quantitative Assessments

Social Symptoms
The patient has endorsed the following social symptoms for the last two weeks or more:

YesNo
For at least two weeks, the patient has been experiencing the following social symptoms:

WithdrawalSocial phobiaIsolationSocial anxietyOther
More information about social symptoms

Educational History
Number of formal years of education
Patient reached fundamental academic milestones (e.g., learning how to read, count, make sounds, etc.) on time.

YesNo
Patient was in regular education throughout primary and secondary education.

YesNo
History of excessive absences and/or latenesses.

YesNo
History of school suspensions and/or expulsions.

YesNo
College Major
Advanced Degree Concentration
More information about educational history

Living Status

Biological Mother
Medical History
Psychiatric History
Biological Father
Medical History
Psychiatric History
More information about other family medical history
If any problems above are endorsed, explain the course of treatment here.

Addiction History (Patient)
Does the patient, currently or in the past, abuse any prescription drugs?

YesNo
List prescription drugs and describe how they are abused.
Does the patient, currently or in the past, have addictive habits?

YesNo

Chemical and Behavioral Addictions

	Age at Start	Age at Stop	Reason for Stopping	Method	Frequency
Marijuana
Alcohol
Nicotine/Tobacco
Cocaine (Powder)
Cocaine (Crack)
Heroin
Pain killers (Oxycotin, Hydrocodone)
MDMA (Ecstasy, Molly)
Steroids
LSD
Hallucinogens
Inhalants
Sex/Porn
Gambling
Eating

Legal History
Does the patient have any pending criminal cases against him/her?

YesNo
Has the patient ever been arrested for a crime?

YesNo
Has the patient ever been jailed for a crime?

YesNo
Does the patient have any pending civil cases?

Yes
Does the patient have a history civil cases against him/her?

YesNo
More information about legal history
If any issues above are endorsed, explain the nature of cases, arrests, and/or jail/prison experiences

Diagnostic Impressions

Recommendations
The following recommendations are made in order to address the patient’s presenting concerns:
1)
2)
3)
4)
5)

	Current Problem	History of Problem	Currently Being Treated	Previously Treated
HIV/AIDS
Psoriasis
Diabetes
Hyperthyroidism (Graves' Disease)
Hypothyroidism
Arthritis
Lupus

	Current Problem	History of Problem	Currently Being Treated	Previously Treated
Clots
Anemia

	Current Problem	History of Problem	Currently Being Treated	Previously Treated
Ulcers
Kidney disease
Bowel movements (irregular)
Constipation
Diarrhea
Urinary tract infections (chronic)
Ulcerative colitis
Crohn's disease
Incontinence
Urination (frequent)
Burning or pain during urination
Blood in stool/Black stools

	Current Problem	History of Problem	Currently Being Treated	Previously Treated
Headaches/Migraines (frequent)
Memory loss
Dementia
Delirium
Stroke
Epilepsy

	Current Problem	History of Problem	Currently Being Treated	Previously Treated
Penetration phobia/difficulty
Orgasm difficulty/inability
Premature ejaculation
Hepatitis
Gonarrhea
Chylamidia
HPV
Syphilis

	Yes	Reported/Documented
Attempted rape
Completed rape
Unwanted touching
Fire
War
Abduction
Childhood physical abuse
Childhood verbal/ emotional abuse
Intimate partner violence
Natural disaster (floods, hurricanes, wild fires)
Witnessing someone get hurt
Witnessing someone get killed

	Ideations	Gestures	Rehearsals	Plans	Attempts
Suicidal
Homicidal

	Age at start	Age at end	Frequency	Reason for stopping
Car racing
Drug dealing
Promiscuity/ Unprotected sex