Adult Psychosocial History

In preparation for our first appointment, please complete the following questions to the best of your ability. The information will help me to better understand your current life circumstances, your concerns, your strengths, and your goals for seeking psychotherapy. Feel free to leave blank any questions that are not relevant to you or that you would prefer not to answer with the exception of the questions related to past experiences with harm to self or others.

Identifying Information

Name*

First NameLast Name

Place of Birth*

Ethnicity

Gender Identification

Psychotherapy Goals

How did you become aware of my services, or who referred you?

What would you like to work on in psychotherapy?

How did you decide that now is a good time to begin psychotherapy?

What are your personal strengths and abilities?

What would you like to be different after completing psychotherapy?

Health and Wellness

Please discuss which wellness, lifestyle and/or self-care practices you engage in regularly.

Present State of General Health

ExcellentGoodFairPoor

Please describe your present sleeping pattern (e.g. hours per night; restful or not; problems getting to sleep or waking early).

Please describe your eating patterns (e.g. number of meals & snacks per day, restrictions).

Please state significant medical problems for which you have been or are being treated.

Please list approximate dates and nature of any surgical procedures.

If you have had any head injuries, please describe, including approximate date(s).

Please list any other accidents or serious injuries.

If you have any disabilities that require accommodation, please describe.

Please list any allergies and indicate whether they are mild, moderate, or severe.

Please list any non-psychiatric medications (prescription and over-the-counter) you are taking, including dose and frequency.

Please provide the approximate date of your last complete physical exam and the results.

Name of your present internist or physician:

How would you describe your sexual orientation?

How many biological children have you had?

Please describe the current state of your sexual health or functioning.

If you have ever experienced or been a partner to someone who has experienced pregnancy loss, please elaborate.

If you or a partner has ever experienced infertility or infertility treatment, please elaborate.

Please indicate the amount and frequency of use of the following.

Past Usage of Alcohol, Caffeine, Nicotine, Marijuana, or other Drugs

Present Usage of Alcohol, Caffeine, Nicotine, Marijuana, or other Drugs

Has anyone every expressed any concerns about your substance use? If so, who?

Has your substance use ever gotten in the way of work/family/social obligations?

Have you ever tried to cut down or stop your substance use? If so, what happened?

Have you ever received any treatment for substance abuse? If so, please describe (e.g. inpatient, outpatient, approximate dates, outcomes.)

Have you ever struggled with any other addictive behaviors (e.g. food, gambling, sex, video games, media/technology)? If so, please describe.

Mental Health

Have you worked with a psychotherapist in the past?

YesNo

If so please give the approximate dates, type (i.e. individual, couple, family) and duration of the therapy(ies).

What was most useful to you in this work?

What do you wish could have been different or more helpful?

Please list any psychiatric medications (i.e. to treat anxiety, depression, inattention, disturbing thoughts, etc.) you have taken or are taking. If more space is needed, please use side or back.

Rows	Medication	Dose	Start Date	End Date	Was it helpful?
1
2
3
4
5
6
7
8

Name of current psychiatrist or prescribing physician:

First NameLast Name

Have you ever had a psychiatric hospitalization?

YesNo

If so, please describe including dates, reason, and outcome.

Have you ever made or threatened to carry out a suicide attempt?*

YesNo

Have you ever harmed or threatened to harm another person?

YesNo

Please indicate relatives with a history of emotional or mental disorder or suicide. If known, please include diagnosis and treatment.

Please note relatives with a history of alcoholism, substance abuse or excessive alcohol use.

Have you ever experienced abuse or harassment?

YesNo

If so, please describe (e.g. physical, sexual, emotional), including when and by whom.

Have you ever had an experience that was life-threatening, overwhelming in emotional intensity or otherwise troubling in some way? If so, please describe.

Relationships and Current Family

If applicable, please give the approximate date your present partner relationship began. If applicable, please provide information about your partner and/or children.

Type a question

Rows	Partner	Child	Child	Child
First Name
Age
City/State
Relationship Status
Number of Children
Education Level
Occupation
Physical Health*
Mental Health*
If deceased, cause/age

* E = Excellent, G = Good, F = Fair, P = Poor

If you have a current relationship with a significant other or partner, please describe your experience of the relationship and any concerns that you have with this present relationship.

Please list any previous marriages or long-term relationships, including first name, year relationship began, year ended, and any children from this relationship.

If you are a parent, please describe your relationship with your children.

What has been most satisfying to you as a parent?

What has been most challenging to you as a parent?

Relationship with Self and Others (Besides Partner)

To whom, if anyone, do you typically turn for emotional support?

Briefly describe the nature and quality of your closest friendship(s).

Please describe any concerns you have about your friendships or friendship patterns.

The questions below ask about things that might have bothered you. For each question, circle the number that best describes how much (or how often) you have been bothered by each problem during the past TWO (2) WEEKS.

Rows	None- Not at all	Slight- Rare, less than a day or two	Mild- Several days	Moderate- More than half the days	Severe- Nearly every day
1. Little interest or pleasure in doing things?
2. Feeling down, depressed and hopeless?
3. Feeling more irritated, grouchy, or angry than usual?
4. Sleeping less than usual, but still have a lot of energy?
5. Starting lots more projects than usual or doing more risky things than usual?
6. Feeling nervous, anxious, frightened, worried, or on edge?
7. Feeling panic or being frightened?
8. Avoiding situations that make you anxious?
9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)?
10. Feeling that your illnesses are not being taken seriously enough?
11. Thoughts of actually hurting yourself?
12. Hearing things other people couldn’t hear, such as voices even when no one was around?
13. Feeling that someone could hear your thoughts, or that you could hear what another person was thinking?
14. Problems with sleep that affected your sleep quality over all?
15. Problems with memory (e.g., learning new information) or with location (e.g., finding your way home)?
16. Unpleasant thoughts, urges, or images that repeatedly enter your mind?
17. Feeling driven to perform certain behaviors or mental acts over and over again?
18. Feeling detached or distant from yourself, your body, your physical surroundings, or your memories?
19. Not knowing who you really are or what you want out of life?
20. Not feeling close to other people or enjoying your relationships with them?
21. Drinking at least 4 drinks of any kind of alcohol in a single day?
22. Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco?
23. Using any of the following medicines ON YOUR OWN, that is, without a doctor’s prescription, in greater amounts or longer than prescribed [e.g., painkillers (like Vicodin), stimulants (like Ritalin or Adderall), sedatives or tranquilizers (like sleeping pills or Valium), or drugs like marijuana, cocaine or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)]?

Education

Please state your highest level of education, including discipline and degree.

Work

How long have you worked at your present job?

What are your specific work responsibilities?

How satisfied are you with your present job?

What aspects of your present job do you enjoy the most?

How are your relationships with your peers and supervisors at work?

Please list other significant jobs you have had along with approximate dates.

Please describe any significant problems in past/present job situations.

Spirituality/Religion

If applicable, describe the role spirituality/religion has played in your life.

Legal

Have you had any past litigation or legal problems?

YesNo

If so, please explain.

Other

Is there anything else you would like me to know about you?

Date*

Date

Signature