Adult History Form (age 15+)

Adult History Form (age 15+)
Problem Assessment
Name

First NameLast Name
Age
Gender

FemaleMaleOther
Please answer the following questions as fully as possible but to the extent at which you are comfortable.
What is your main concern/stressor?

Marital issuesParent or child issuesHealth issuesIssues of the past (e.g. guilt, abuse, neglect, family-of-origin issues, etc.)Employment-related issuesFinancial issuesAddictionTraumaSignificant loss (e.g. job, home, relative/significant other, pet, etc.)Other
What are your main symptoms?

Anxiety/worry/panicDecreased energyDecreased concentrationDecreased motivationSad moodDecrease in interest or pleasureChange in appetite (either eating less or eating more)Mood swingsAnger problemsThoughts of death/suicideOther
Have you ever attempted either or both of the following?

SuicideHomicide
If yes, please describe:
Is there a history of suicide in your family?
If yes, please explain:
Have you ever inflicted burns or wounds to yourself?
If yes, please describe:
Are you presently suicidal/homicidal?
Please describe any other risk-taking behaviors you currently engage in or historically have engaged in:
What are you experiencing that has prompted you to seek counseling?
When did these problems develop?
Please list your strengths:
Please list your weaknesses:
Mental Health History
Have you ever had previous out-patient mental health treatment?
If yes, please provide name of the place or professional you saw, the length of treatment, and the date(s):
Have you ever been admitted to the hospital for mental health or addiction issues:
If yes, please provide the name of institution(s) and the date(s):
Please provide any previous psychiatric diagnosis you may have received:
Please list any psychiatric medications you have been on, past or present:
If you have taken them, which psychiatric medications have been helpful?
Medical History
Please describe your current condition of health including any disabilities or disorders:
Please describe any accomodations you may need:
Are you currently on any medications?
If yes, please list them and include dosage as well as the name of the prescribing physician:
Has it been over a year since your last physical exam, including bloodwork?
Have you ever had an abortion (females) or had a child of yours aborted (males)?
If yes, when was the abortion performed?
Do you have any allergies?
If yes, please describe what you are allergic to:
Please list any previous health problems, operative procedures, and/or medical hospitalizations including the date(s):
Substance Use History
Please indicate which of the following substances you have used or are currently using:

AlcoholStreet drugs (e.g. methamphetamines, cocaine, crack cocaine, heroin, etc.)Tobacco (e.g. cigarettes, snuff, chew, vape)MarijuannaCaffeineOther
If you have used any of these substances, please indicate which one, when you first used it and the last time you used it. If currently using, please indicate how often you use it:
Have you experienced a recent increase in the use of your substance(s) of choice?
Do you, your friends, or your family members see your current usage as a problem?
If yes, when did it become problematic?
Please describe any family history of substance abuse:
Nutrition
Do you feel you have balanced, healthy eating patterns?
Do you have a lot of concerns about your weight and shape?
Do you ever eat out of boredom, anger, or depression?
Do you ever feel out of control when you eat?
Do you ever purge after eating (e.g. self-induced vomiting, taking laxatives, etc.)?
Are you comfortable eating in front of others/in a group?
Do you, or others, believe you exercise excessively?
Legal History

Please explain all that apply.
Charges as a minor:
Present charges:
Arrests (when and why):
Incarcerations (when and why):
Parole/probation (if currently on parole, please provide parole/probation officer's name and number):
Bankruptcy:
Civil lawsuit:
Child custody problems:
Developmental History
Please list the members of your family of origin and describe how you got along with each of them while growing up:
Who primarily raised you?
How would you describe your childhood?

TraumaticUneventfulGood/happyOther
If you marked traumatic, please provide the date, your age, and the traumatic event(s) you endured:
What were you like as a child? (Include friends, school, hobbies, personality, etc.)
Trauma History
Have you ever experienced unwanted sexual interaction?
If yes or unsure, please explain to the extent you feel comfortable:
Have you ever been the victim of abuse, neglect, or violence?
If yes, please explain:
Have you ever witnessed abuse, neglect, or violence towards another person?
If yes, please explain:
Have you ever been the perpetrator of abuse, neglect, or violence towards another person?
If yes, please explain:
Please list any other traumatic events you have endured as an adult. Include date of event:
Residential History
Where do you currently live?

At parent's/relative's homeWith roommate(s)With spouse/significant otherAloneHomeless/in a shelterWith spouse/significant otherOther
Are you content with your residential situation?
If no, what would you like to change?
Support Network and Hobbies
Who can you count on for support?

ParentsSpouse/significant otherSiblingsFriend(s)EmployerFaith communityTherapistNeighbor(s)Other
What are your hobbies or leisure activies?
Marital/Relationship History (if applicable)
Are you currently:

MarriedIn a committed relationshipSeparatedDivorcedSingleWidowedHaving an affairPracticing polygomyOther
If you are married or in a committed relationship, how long have you been married or in this relationship?
What is the name and age of your spouse/significant other?
If you were previously married or in a committed relationship, when did you divorce or break up? Do you have children from that relationship?
What is your perception of your current marriage/relationship (include communication patterns, problems, sexual relations, etc.)
If you have children, please list the names, ages, and relationship dynamics between you and each of them:
Work History
Please describe your current job/career:
Please describe your relationship with your supervisor and co-workers:
How many jobs have you held in the past five years?
Have you ever experienced the following:

FiredLaid offQuit without notice
If yes, please explain:
Financial Situation
Please briefly describe your current financial situation:
Military History
Please list branch, dates, and duties:
Family Involvement
Would it be beneficial for any member(s) of your family, or your guardian,to attend or be communicated with regarding your therapy?
If yes, please provide the name(s) and number(s) of who you would like to be included:
If we may contact any of the people above for their input in and involvement in your care, please indicate who:
What is your family's/legal guardian's perception of your difficulties?
Religious/Cultural Factors
What is your religious background?
What is your current religious affiliation, if any?
Please describe your spirituality/what you believe:
Please list anything positive or negative that is important regarding your culture or ethnicity:
Educational History
What was school like for you? What kind of grades did you have?
Highest level of school completed:

ElementaryMiddle schoolHigh schoolSome collegeBachelor's degreeMaster's degreeDoctoral degreeTrade school certification
Are you currently in school?
If yes, what grade are you in or what level of post-graduate studies are you in?
Miscellaneous
Please describe anything else that would be helpful to know about you:
What would you like to accomplish during your treatment with TransitionWell Counseling & Consulting?
Signature
Date

MonthDayYear
Date
Thearpist Signature
Date

MonthDayYear
Date
Should be Empty: