TOM EDWARDS, LCSW
ADULT PATIENT QUESTIONNAIRE
Name
First Name
Last Name
Date of Completion
-
Month
-
Day
Year
Date
Referred by:
Please summarize the primary issue or concern that brings you to therapy:
Please describe any previous mental health treatment you have received:
Please list any medications you are currently taking, including dosage and name of prescriber:
Please indicate if you have had any of the following difficulties:
Anxiety
Please Select
Never
Rarely
At times
Frequently
Constantly
Depression
Please Select
Never
Rarely
At times
Frequently
Constantly
Significant Mood Swings
Please Select
Never
Rarely
At times
Frequently
Constantly
Difficulty Paying Attention
Please Select
Never
Rarely
At times
Frequently
Constantly
Concentration Problems
Please Select
Never
Rarely
At times
Frequently
Constantly
Racing Thoughts
Please Select
Never
Rarely
At times
Frequently
Constantly
Problems with Emotional Regulation
Please Select
Never
Rarely
At times
Frequently
Constantly
Violence
Please Select
Never
Rarely
At times
Frequently
Constantly
Abuse of Alcohol/ Other Substances
Please Select
Never
Rarely
At times
Frequently
Constantly
Conflict with Family
Please Select
Never
Rarely
At times
Frequently
Constantly
Conflict with Peers/ Coworkers
Please Select
Never
Rarely
At times
Frequently
Constantly
Self Harming Behaviors
Please Select
Never
Rarely
At times
Frequently
Constantly
Suicidal Ideas/ Attempts
Please Select
Never
Rarely
At times
Frequently
Constantly
Paranoid Thinking
Please Select
Never
Rarely
At times
Frequently
Constantly
Unusual Perceptual Experiences/ Hallucinations
Please Select
Never
Rarely
At times
Frequently
Constantly
Please describe your general sleeping habits:
Please describe any issues related to appetite or unhealthy eating habits:
Please describe any other problematic and/or addictive behaviors:
Please describe any history of traumatic events:
Are you currently working with any other mental healthcare providers?/ If so, please list:
Please describe your current living situation (Marital status, members of household, setting:
Please provide details of your academic history:
Please provide details of your work history, including any current employment:
Please provide any family history of mental health concerns, substance abuse or other addictive behaviors, abuse, neglect, and other significant factors:
Any other issues that have not been covered but are relevant:
Please indicate what you hope to gain from therapy, including any goals, expectations, etc.:
Submit
Should be Empty: