Name _______________________________ Today’s Date _____________ Case # _____________

Briefly describe your reason(s) for seeking help:

How long have you had the problem(s)?

Why did you decide to seek help now?

What other ways have you tried to deal with this problem?

History of treatment for emotional problems and family history

Outpatient treatment o yes o no
Did it help? o yes o no
Therapist’s name ____________________________________
Dates in treatment _________________
Inpatient treatment o yes o no
Where ______________________________________________
When ______________________________________________
How long ___________________________________________
Family history of emotional problems o yes o no
Who _______________________________________________
Relationship to you ____________________________________

Check any of the following items that apply to you:

o Thoughts of suicide o Thoughts of harming others o Phobias
o Trouble getting to sleep o History of attempts to kill yourself o Panic attacks
o Waking during the night o Cutting or otherwise hurting yourself o Excessive guilt
o Waking early every day o Feelings of hopelessness o Forgetfulness
o Financial problems o Inability to make decisions o Mood swings
o Loss of appetite o Trouble controlling your temper o Health problems
o Hearing voices o Large weight gain or loss o Family problems
o Problems at work o Seeing things others don’t o Violence toward others
o Trouble concentrating o History of physical abuse o Tingling or numbness
o Racing thoughts o History of sexual abuse o Depressed mood
o Legal problems

(Please complete the other side of this form)
Health Status
List any medical problems or physical problems and when they were diagnosed
1. ____________________________
2. ____________________________
3. ____________________________
List any major (where you were put to sleep) surgeries you have had to date
1. ____________________________
2. ____________________________
3. ____________________________
List any serious illness or injuries especially anything involving the head
1. ____________________________
2. ____________________________
3. ____________________________
List any allergies to foods or drugs
1. ____________________________ 3. ____________________________
2.____________________________  4. ____________________________
Date of last physical examination _______________ Doctor’s name _____________________
May we contact your doctor?  o yes       o no

Drug and Alcohol Information
List all of the prescription and over-the-counter drugs you are taking

Check substances you use in any amount at all How much do you use per

Age first used




Last Used

o Beer
o Liquor
o Wine
o Marijuana
o Cocaine/Crack
o Methamphetamine/Crystal
o Heroin
o Barbiturates (downers)
o PCP, LSD (Hallucinogens)
o Tobacco (in any form)
o Other___________________

To be completed by adults (18 yrs and older)

Have you ever felt like you should cut down on your drug or alcohol use? o yes    o no
Has a friend or relative expressed concerns about your use? o yes    o no
Have you ever felt guilty about your drinking or drug use? o yes    o no
Have you ever had to take a drink or use a drug the next day to steady your nerves? o yes   o no
Are you a recovering alcoholic or a recovering drug addict? o yes   o no
Is there a history of problems with drug or alcohol use in your family? o yes   o no

To be completed by adolescents (12 yrs to 17 yrs)

Have you ever used alcohol or drugs before or during school? o yes   o no
Have you ever missed school (or been truant) because of use or just to use? o yes   o no
Have you ever avoided non-users? o yes   o no
How often do you get drunk/high?___________________________
About how often do you use more than one drug when you get high? _____________
Is there a history of problems with drug or alcohol use in your family? o yes   o no

______________________________________________ _____________________________________________
Therapist Date Client signature Date



My Office Location

12600 E US 40 Highway, Suite 101

Independence, MO 64055

My office is conveniently  located on 40 Highway near Crysler.

Near by cities include Blue Springs, Oak Grove, Raytown and Lee’s Summit.