Psychology

Client Name______________________________________ Chart # ______________________

Evaluating Counselor _____________________________________ Date __________________

Please indicate “NA” if the question/section is not applicable to the client’s history. DO NOT LEAVE ANY SECTION/LINE BLANK.

Presenting Problem: (Include the client’s own words about why the services are needed, any referrals, and major stressors over the past six months.)

Past Treatment History: (Include past treatment history for substance abuse AND mental health services.)

Family History: (Include biological family members, number of children, divorce, separations; describe what it was like growing up in this family, and include substance abuse and psychiatric history of family members.)

Substance Abuse Drug History: (Include top three drugs of choice.)

1.

2.

3.

List any withdrawal symptoms as reported by client (sweats, constipation, DTs, seizures, etc.):

Social History

Client’s Current Life Situation: (Summarize present living arrangements and any current social supports.)

Sexual Orientation:

Spiritual Beliefs:

Employment History

Employment: (Include longest continuous employment, type of employment, typical length of stay, present employment, and military history.)

Education: (Note highest level of schooling completed, school performance, peer relationships, and learning problems.)

Medical Health History: (Include illnesses, surgeries, medications [OTC and prescription]. Note any current medical problems, physical disabilities, and/or eating disorders. Include gynecological history and pregnancies.)

Primary Care Physician:

Name: _________________________________________________________

Address: _______________________________________________________

Phone: ______________________________ Fax: _______________________

Date of Last Physical Exam: ____________________________________

Hospital of Choice: ___________________________________________

Allergies: ______________________________________________________

Medical Medications: (Include name of medication, dose, condition it is treating, and its effectiveness.)

_____________________________________ ___________________________________

_____________________________________ ___________________________________

_____________________________________ ___________________________________

Mental Health/Psychiatric History:

Have you ever been treated for a psychiatric illness: Yes or No

Please explain: (Include if client has been hospitalized, seen by a mental health professional, what they were seen for, and how long they were seen.)

Any SI/HI or plan in past or present? (Please explain if “yes”)

Psychiatric Medication History:

Legal History: (Note any charges and dates, any outstanding warrants, court dates, description of crimes, convictions, incarcerations, etc.)

· No legal issues

· Currently on probation

· Pending warrants

· Jail term served

· Court cases pending

· Parole

Explain with detail any and all of the above checked:

Clients Self-Assessment of Strengths:

1. ______________________________

2. ______________________________

3. ______________________________

Clients Self-Assessment of Weaknesses

1. ______________________________

2. ______________________________

3. ______________________________

4.

Recommendations: (This narrative section pulls all of the information together, with a clinical opinion about what the primary issues are and what should be done to address them. Also state potential referrals to rehabilitative, IOP, and so on that are appropriate at this time.)

Clinician/Counselor Signature: ____________________________________ Date: ___________

Clinical Director Signature: _______________________________________ Date: ___________