New Patient Information Mid Towne – Adult Date* MM slash DD slash YYYY Legal Name* First Last Preferred Name First Last Biological Sex* Preferred Gender Pronoun: Gender Identity Birth Date* MM slash DD slash YYYY Age*Presenting Problems (check all that apply)Tired or Fatigued* None Mild Moderate Severe Tension or Anxiety* None Mild Moderate Severe Sleep Disturbance* None Mild Moderate Severe Arguing with Significant Other* None Mild Moderate Severe Feelings of Guilt* None Mild Moderate Severe Concentration / Attention Problems* None Mild Moderate Severe Abuse or Related Problems* None Mild Moderate Severe Marital Problems* None Mild Moderate Severe Problems with Children* None Mild Moderate Severe Sexual Concerns* None Mild Moderate Severe Alcohol or Drug Use Problems* None Mild Moderate Severe Physical Complaints* None Mild Moderate Severe Memory Problems* None Mild Moderate Severe Irrational Fears* None Mild Moderate Severe Work-related Problems* None Mild Moderate Severe Eating Problems* None Mild Moderate Severe Depression* None Mild Moderate Severe Anger* None Mild Moderate Severe Do you hear voices?* None Mild Moderate Severe Do you see things that aren’t there?* None Mild Moderate Severe Suicidal Thoughts* None Mild Moderate Severe Homicidal Thoughts* None Mild Moderate Severe Self-Harm* None Mild Moderate Severe Gender Identity* None Mild Moderate Severe Other Other (described above) None Mild Moderate Severe Mental Health History No Mental Health History Have you received counseling in the past?* Yes No If yes, when, with whom, and for what reason?Have you been hospitalized for a mental health issue?* Yes No If yes, when and for what reason?Is there a family history of mental health problems or nervous problems?* Yes No If yes, please explain.Substance Use HistoryAlcohol* None Past Present Frequency / Amount Drugs* None Past Present Frequency / Amount Nicotine* None Past Present Frequency / Amount Caffeine* None Past Present Frequency / Amount Have you received treatment for any of the above substances?* Yes No If yes, when, for what substance and for how long? Do you have any family members with substance abuse problems?* Yes No If yes, list relationship and substance abused.Medical HistoryWho is your current Primary Care Physician?* Date of last visit* MM slash DD slash YYYY Describe any present or past health concerns/problems, including any childhood traumas or surgeries.List all medications and dosages you are currently taking.Height Weight Appetite Family/Social/Personal HistoryParent’s marital status:* Married Separated Divorced Never Married If divorced, number of times divorced If married, how would you describe the quality/satisfaction of their marriage?Describe your relationship with your father and mother.List your sibling's name, gender, age, marital status, and occupationDescribe your relationship with your siblings.Describe your childhood/adolescent years. (Attitude, feelings, like, dislikes, etc.)*Is there any history of verbal, physical, or sexual abuse in your family?* Yes No If yes, please describe.Describe your current family relationships and living arrangements.*List and describe your support system of family and friends.*Do you gamble?* Yes No If yes, how often? Have you used porn?* Yes No If yes, how often? Do you or have you been told that you have issues with food?* Yes No Do you or have you been told that you have issues with over spending?* Yes No Relationship HistoryRelationship Status* Single Married Separated Divorced Living Together Dating If married, number of years If separated, date of separation If divorced, date of divorce If living together, number of years Name of Spouse / Partner How many times have you been married and what was your age and your partners? If divorced, please give reason.If in a relationship, how would you describe the quality/satisfaction of your present relationship?How many children do you haveBiological childrenAdopted childrenFoster childrenList your children's names, age, marital status, and city and stateHow would you describe your relationship with your children?Legal HistoryNumber of arrests Number of substance-related arrests Number of OUIL, DUIL, or DWI arrests Nature of other arrestsOther legal concernsReligious / Spiritual BackgroundList any formal religious affiliation.Please describe your involvement.Cultural / Racial Identity:Please choose* White/Caucasian African American Asian Hispanic American Indian Middle Eastern Muslim Hindu/Buddhist Other/not listed Therapist's Name*
