Mental Health History & Presenting Concerns
Patient/Client Name
First Name
Last Name
Date of Birth
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Preferred Pronoun
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient/Client Phone Number
-
Area Code
Phone Number
Patient/Client Email
example@example.com
Emergency/Guardian Name
First Name
Last Name
Emergency/Guardian Number
-
Area Code
Phone Number
Emergency/Guardian Email
example@example.com
Do you authorize communication via text?
Over the last 2 weeks, how often have you, or your child, been bothered by or experienced any of the following problems?
Not at all-0
Several Days
More than half the days
Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed or hopeless
3. Trouble falling or staying asleep, sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite-being so figety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself
10. Panic attacks, or feeling so paralyzed you cannot move
11. Avoiding responsibilities
12. Use substances (e.g., alcohol, marijuana, etc.), either to pass time or to better manage your symptoms
How difficult have the above experiences made it for you, or your child, to do your/their work, take care of things at home, or get along with other people?
1
2
3
4
5
Not difficult
Very difficult
1 is Not difficult, 5 is Very difficult
What are you, or your child's, current coping strategies or activities that you/they have done to feel better or deal with the above-mentioned challenges?
What brings you to counseling today?
Have you/your child participated in counseling in the past?
YES
NO
If YES, when?
Is the patient taking psychotropic medications?
YES
NO
If YES, write the name(s) below
Name of Prescribing Physician
Has the patient ever been admitted to a hospital/facility for psychiatric care?
YES
NO
If YES, include Month/Year
Back
Next
Strengths & Challenges
Please provide any additional information you wish to share below; include specifics regarding you, or your child's strengths and/or the challenges in your life that are associated with each of the categories listed below.
Family Dynamics
Social Relationships
Education
Employment History
Chemical History
Spirituality
Health
How did you hear about Behavioral Learning?
Psychology Today
Internet Search
BACB Website
Insurance Website
Friend/Family Member
Another ABA Provider
Submit
Should be Empty:
Now create your own JotForm - It's free!
Create your own JotForm