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FindingStone
Counseling Center - CONFIDENTIAL CLIENT INFORMATION |
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Name: |
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Email
Address: |
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Home Address:
Street:
City
Zip code
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Age: |
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Gender
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Phone: |
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Relationship
Status: |
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Current
Living Arrangement: |
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Time
lived at current residence: |
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Have
you ever received psychological / counseling / psychiatric
services? |
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If "yes", please describe:
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Level
of completed education: |
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Current
employment situation: |
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Current
medications: |
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if
yes, please list name and dosage
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PROBLEM
CHECKLIST (check
any symptoms that apply whether problem heading is correct or
not) |
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Depression |
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chronic
sadness |
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low
frustration tolerance |
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crying
episodes |
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irritability |
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hopelessness |
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sleep
problems |
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difficulty
concentrating |
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memory
problems |
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weight
loss |
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thoughts
of suicide |
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weight
gain |
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withdrawing
from others |
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loss
of appetite |
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difficulty
functioning at work |
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overeating |
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difficulty
functioning socially |
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nausea/vomiting |
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low
energy/fatigue |
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difficulty
making decisions |
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reduced
interest/pleasure |
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recurring
thoughts of death or dying |
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feelings
of worthlessness/guilt |
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Anxiety |
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agitation |
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panic
attacks |
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restlessness |
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fear of
leaving home |
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excessive
worry |
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avoidance
of public places |
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fearfulness |
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avoidance
of social situations |
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trembling/shaking |
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pounding
heart/palpitations/shortness of breath |
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fear of
loss of control |
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chest
pain |
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fear of
dying |
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Stress/Trauma |
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Feeling
detached from others/life |
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Flashbacks/re-living
bad experiences |
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Intrusive
thoughts of bad memories |
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Easily
startled/upset |
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Nightmares |
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Substance
Abuse |
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Excessive
use of alcohol/drugs |
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Fail at
effort to reduce use of alcohol/drugs |
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Use
substances to cope with difficult feelings/life problems |
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Legal
problems related to substance use |
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History
of substance abuse in family |
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Cigarette
use is troublesome/causing health problems |
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Memory
loss following substance use |
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Unconsciousness
due to substance use |
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Health
problems/accident(s) due to substance use |
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Substance
use causing problems problem
with friends/family/work |
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Eating
Problems |
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Excessive
eating |
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Obesity |
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Underweight |
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Self-induced
vomiting |
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Use
of laxatives |
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Obsessing
about food, diet, exercise |
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Eating
problems interfering with health |
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Thinking
Problems |
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Hearing
voices others do not hear |
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Seeing
things others do not see |
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Fearful
others are talking about you |
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Fearful
someone is plotting against you |
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Attention
and Behavior |
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Difficulty
completing tasks/distractible |
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Taking
on more tasks than can be completed |
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Difficulty
focusing |
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Frequent
forgetfulness |
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Tendency
to be impulsive |
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Difficulty
waiting your turn |
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Not
well organized |
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Difficulty
at work/do not stay on the same job |
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Problems
with co-workers |
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Problems
with co-workers |
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Problems
with legal authorities |
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Problems
in school growing up |
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Other
Problem Areas |
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Racing
thoughts |
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Staying
up for days without sleep |
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Excessive
spending |
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Excessive
gambling |
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High
risk sexual behavior |
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Aggressive/abusive
toward others |
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Confused/worried
about sexual behavior |
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Marital
conflict |
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Parent-child
conflict |
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Other
family conflicts |
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When
describing your problem (below) you will help your therapist
to provide
the best possible and most relevant response, if you include
the following information:
1. Describe the problem in a very specific and understandable
way.
2. How
long has the problem been present? (When/How did it start?)
3. Why did you decide to seek help now, through e-therapy?
4. Who is involved/affected by the problem.
Describe their involvement.
5. What have you already done to try to solve the problem?
What has helped
(even if only a little) and what has failed to
help?
6. What would the first small sign be that tells you the
problem
is beginning to improve or change for the
better?
*Do not use the "enter" key
it will submit your form.
Continue typing and the form will format your response.
Using
the suggestions/questions and problem/symptom checklist
above as a guide, please give your therapist a summary of the
problem
you want help with (Use as much space as you need.
(Do not hard return using the
enter key) |
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Now that you
have described the problem, please ask your therapist
the specific question(s) you would like answered, in relation
to your
problem, that will provide you with the information you need
in order
to take the steps that will begin to improve your situation.
(Use as much space as you need.
(Do not hard return using the
enter key))
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Preferred
appointment times - Enter the times that work best for you.
We will try to schedule you accordingly, but can't guarantee
the times
you request are available. |
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