Please take your time in providing the following information. The questions are designed to help me begin to understand you so that our time together can be as productive as possible. All information provided is confidential.Referred byMedical Provider: Insurance Provider: Psychology TodayMy Website: drcareyoneill.comFriend/Family: Other: Have you previously received any type of mental health services? Yes No If yes, which of the following: Psychotherapy Medication Hospitalization If yes, please provide:Name of provider or facility: Location Dates of treatment Reason for treatment Briefly, what brings you in today When did your problem first start? Within the last: 30 days 6--12 month 2 years During adolescence During childhood What areas of your life have been affected because of this problem? Are you currently experiencing overwhelming sadness, grief or depression? Yes No If yes, for approximately how long? Are you currently experiencing anxiety, panic attacks or have any phobias? Yes No If yes, when did you begin experiencing this? describe any major losses or traumas you have experienced: What significant life changes or stressful events have you experienced recently? What would ou like to accomplish out of your time in therapy Family History Where were you born? Where did you grow up? City Suburbs Country Please list your parents and siblings. Please use additional space on the back if neededNameAgeRelationshipWhere do they live now?If deceased, age and cause of death Add RemoveWho did you live with while growing up? Mother's occupation Father's occupation? Condition Please circleList Family Member Alcohol/Substance Abuse yes/ no Anxiety yes/ no Depression yes/ no Domestic Violence yes/ no Sexual Abuse yes/ no Eating Disorders yes/ no Obesity yes/ no Obsessive Compulsive Disorder yes/ no Schizophrenia yes/ no Suicide Attempts yes/ no Other diagnosed mental health condition? yes/ no : which was--- Marital Status: Never Married Domestic Partner Married Separated Divorced -- For how long? Widowed: Please provide your partners name and year deceased: If married, how long have you been married for and what is your partners name: On a scale of 1-10 (best), how would you rate your relationship? Are you currently in a romantic relationship?Yes -- How long? No On a scale of 1-10 (best), how would you rate your relationship? Please list any children, their names, and ages:NameAgeRelationshipName of other parentIf deceased, age and cause of death Add RemovePhysical Health Please list any medications, herbs, or supplements. Be sure to include the condition, as some medications are prescribed for offlabel use. Continue on the back if needed, or provide a separate list. If you have a complicated medical profile, please supply supporting documentation to be able to facilitate a comprehensive understanding of your health. Medication/SupplementDosageConditionDate Began/Stopped Add RemovePrescribing provider and contact information:Name Specialty Facility Phone, email, or Fax: How would you rate your current physical health? Poor Unsatisfactory Satisfactory Good Very Good Please list any specific health problems you are currently experiencing:How would you rate your current sleeping habits? Poor Unsatisfactory Satisfactory Good Very Good If you are having problems, in which phase of sleep are you experiencing issues? Falling asleep Staying asleep Awakening early Sleep apnea Please list any other specific sleep problems you are currently experiencing: How many times per week do you generally exercise? What types of exercise do you participate in: Are you currently experiencing any chronic pain? Yes No If yes, please describe: Please describe current use of alcohol, cigarettes, and/or recreational drugs Please describe previous use of alcohol, cigarettes, and/or recreational drugs: Additional InformationWhat do you enjoy about your work (full-time homemaker included)? If retired, what did you enjoy about your work? What do you find particularly stressful about your current or previous work? What do you enjoy doing in your free time? What do you do to relax? Do you consider yourself to be spiritual or religious? If yes, please describe your faith or belief: What do you consider to be some of your strengths? What do you consider to be some of your weakness?
