MCO/TRI Adult Interview

MEDICATIONS
Current Medication and Dosage
MENTAL HEALTH HISTORY
Any history of emotional/psychological problems with a family member?

Yes No
If yes, who and what type?
Any history of alcoholism in your family?

Yes No
If Yes, who and what type?
Has any relative attempted or committed suicide? member?

Yes No
If yes, who was the family
Have you ever had any emotional/psychological problems or difficulty coping with emotional stress?

Yes No
If Yes, please explain:

SOCIAL HISTORY (MARITAL/RELATIONSHIP)
What is your current marital/relationship status?

Married Separated Divorced Single Living with someone
If married, for how long?
List the first name, age and sex of child(ren) from the marriage:
If divorced, provide pertinent details (dates, reason for divorce, etc.).
If children from other relationships, list the sex and age of these children.
Who lives at home with you?
How would you describe your social/emotional support system?

My financial situation is a major stressor at this time.

Yes No - If yes, please explain.
If Yes, please explain:
Social History (General)
List the city, state and county of your birth:
If you weren't born in the US, when did you come here?
Are you a permanent US resident?

No Yes
What is your primary language?
By whom were you raised? If not by your parents, please explain why.
Overall, how would you describe the family in which you were raised? (i.e. happy, strict, religious, dysfunctional, etc.)
How many brothers and sisters do you have? If any are deceased, please list the year and cause of death.

Please list previous jobs below:

Company/Job Title

How long?

Reason for leaving

Previous Job

Have you served in the military?

Yes No
If Yes, list Division, Rank and type of discharge. List any combat experience:
What is the highest grade you completed in school?
Please list any school(s) attended, degrees/diplomas received and/or certifications held.
What activities and interests do you pursue in your leisure time?

Legal History
Do you have any history or trouble with the law?

Yes No
If Yes, please explain:
What are your personal/social/work goals (include goals relating to your children, family relationships, working/vocational retraining, health, social activities, sports/hobbies, etc.
1.
2.
3.
The information I have provided in this questionnaire is true and accurate to the best of my knowledge and recollection.
NAME (PLEASE PRINT) *
SIGNATURE *

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