LTC Application Form Intake FormNote:This questionnaire is for the purpose of getting to know you better in order to provide the best possible mental health services. Please complete this form as honestly and completely aspossible. All information that you provide us will be confidential as required by state and federal law.Client Full Name: *Street Address *City *State/Province *ZIP / Postal Code *Home Phone: *May we leave you a message? *YesNoCell/Other Phone: *May we leave you a message? *YesNoE-mail: **Please note: Email correspondence is not considered to be confidential medium of communication•May we email you? *YesNoBirth Date *Gender: *MaleFemaleOtherAge *SS$# *Note:IF UNDER 18 YEARS, Name of parent/guardianFirst Name *Middle InitialLast Name *Client Ethnicity *White/CaucasianAsian or Pacific IslanderHispanic/LatinoAfrican/AmericanNative American or Alaskan NativeNote:This information will be used for classification purposes only.Client or Parent(if under 18) Marital Status: *Never MarriedDomestic PartnershipMarriedSeparatedDivorcedWidowedPlease list first name(s) and age(s) of client's child (children):Referred by (if any):Emergency Contact InformationName *Relationship *Local Phone# *Permission to call (client signature): *Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)? *YesNoPrevious therapist/practitioner:Are you currently taking any prescription medication? *YesNoPlease List:Have you ever been prescribed psychiatric medication (e.g., antidepressants, anti-anxiety)? *YesNoPlease list medication(s) and provide dates:Are you a veteran of the U.S. Armed Forces? *YesNoWhich branch?Do you serve in combat? *YesNoAdvance Directives FormSelectDNRDNIFull CodeGeneral Health InformationI. How would you rate your current physical health? *PoorUnsatisfactorySatisfactoryGoodVery GoodPlease list any specific health problems you are currently experiencing: *2. How would you rate your current sleeping habits? *PoorUnsatisfactorySatisfactoryGoodVery GoodPlease list any specific health problems you are currently experiencing: *Date of last medical exam: *Family Doctor: *Phone: *Address: *4. Do you currently have. or have you ever had any of the following health problems? *High blood pressureHeart diseaseStrokeDiabetesCancerAsthmaHead InjuriesKidney DiseaseJaundice of LiverAnemiaThyroid/EndocrineSTDUlcer/GastritisEpilepsy/Seizure5.How many times per week do you generally exercise? *What types of exercise to you participate in?6. Please list any difficulties you experience with your appetite or eating patterns: *7. Are you currently experiencing ovemthelming sadness, grief, or depression? *YesNoIf yes, for approximately how long?8. Are you currently experiencing anxiety, panic attacks, or have any phobias? *YesNoIf yes when did you begin experiencing this?9. Are you currently experiencing any chronic pain? *YesNoIf yes, please describe:10. Do you drink more than once a week? *YesNoI I. How often do engage recreational drug use? *DailyWeeklyMonthlyInfrequentlyNever12. Are you currently in a romantic relationship?YesNoIf yes, for how long?On a scale of 1-10, how would you rate your relationship?13. What significant life changes or stressful events have you experienced recently: *14. Are you considering suicide? *YesNo15. Have you ever made an attempt to commit suicide?YesNo16. Do you have a plan to commit suicide?YesNo17. Have you had any legal issues in the past?YesNoIf yes, please explain:18. Have you experienced any situations of abuse (physical, psychological, sexual)?YesNoIf yes, please explain:SymptomsPlease check any symptoms or experiences that you have had in the last monthSelect SymptomsDifficulty falling asleepDifficulty getting out of bedPersistent loss of interest in previously enjoyed activitiesSpending increased time aloneFeeling numbIrritabilityPanic attacksAvoiding people, places, activities or specific thingsDifficulty staying asleepNot feeling rested in the morningWithdrawing from other peopleDepressed moodRapid mood swingsAnxietyFrequent feelings of guiltDifficulty leaving your homeFear of certain objects or situations?Outbursts of angerHopelessnessHelplessnessFeeling or acting like a different personEating more ovoluntary vomitingExcessive exercise to avoid weight gainAre you trying to lose weightWeight lossIncrease muscle tensionEasily startled?Repetitive behaviors or mental actsWorthlessSadnessFearChanges in eating/appetiteWating lessUse of laxativesBinge eatingWeight gain a difficulty catching your breathUnusual sweatingIncreased energyDecreased energyDizzinessPhysical sensations others don't haveIntrusive memoriesLarge gaps in memoryTremorFrequent worryRacing thoughtsDifficulty concentrating or thinkingFlashbacksNightmaresThoughts about harming or killing someone elseFeeling puzzled with realityUnusual visual experiences such as flashes of light or shadowsFeeling that your thoughts are controlled or placed in your mindDiffculty problem solvingDependency on othersInappropriate expression of angerDifficulty saying "no" to othersSense of lack of controlAbusive relationshipConcerns about your sexualityThoughts about harming or killing yourselfFeeling as if you were outside yourselfPersistent, repetitive, intrusive thoughts, impulses, or imagesHear voices when no one else is presentFeeling that the television or the radio is communicating with youDifficulty meeting role expectationsManipulation of othersSelf mutilation/ cuttingIneffective communicationDecreased ability to handle stressDifficulty expressing emotionsAre you apart of the LGBTQ+ community?YesNoFamily HistoryFather InfoFather Name:Age:Occupation:Health:Is he Living or Deceased?LivingDeceasedIf deceased, HIS age at time of his death:YOUR age at time of his death:Cause of his death:Frequency of contact with him:Are you/Have you been close to him?Mother InfoMother NameAge:Occupation:Health:Is she Living or Deceased?LivingDeceasedIf deceased, HER age at time of her death:YOUR age at time of her death:Cause of death:Frequency of contact with her:Are you/Have you been close to her?Brothers & SistersName:Sex:Age:Whereabouts:Are you close to him/her?YesNoDuring your childhood, did you live any significant period of time with anyone other than your natural parents?YesNoIf so, please give the persona's name and relationship to you.Name:Relationship to you:Please place a check mark in the appropriate box if these are or have been resent in our relativesChildrenNervous ProblemsDepressionHyperactivityCounselingPsychiatric MedicationPsychiatric HospitalizationSuicide AttemptDeath by SuicideDrinking ProblemIf these are or have been resent in your childrenBrothersNervous ProblemsDepressionHyperactivityCounselingPsychiatric MedicationPsychiatric HospitalizationSuicide AttemptDeath by SuicideDrinking ProblemIf these are or have been resent in your brothersSistersNervous ProblemsDepressionHyperactivityCounselingPsychiatric MedicationPsychiatric HospitalizationSuicide AttemptDeath by SuicideDrinking ProblemIf these are or have been resent in your sistersFatherNervous ProblemsDepressionHyperactivityCounselingPsychiatric MedicationPsychiatric HospitalizationSuicide AttemptDeath by SuicideDrinking ProblemIf these are or have been resent in your fatherMotherNervous ProblemsDepressionHyperactivityCounselingPsychiatric MedicationPsychiatric HospitalizationSuicide AttemptDeath by SuicideDrinking ProblemIf these are or have been resent in your motherUncle/AuntNervous ProblemsDepressionHyperactivityCounselingPsychiatric MedicationPsychiatric HospitalizationSuicide AttemptDeath by SuicideDrinking ProblemIf these are or have been resent in your uncle/auntGrandparentsNervous ProblemsDepressionHyperactivityCounselingPsychiatric MedicationPsychiatric HospitalizationSuicide AttemptDeath by SuicideDrinking ProblemIf these are or have been resent in your grandparentsSocial HistoryPast Marital HistoryHave you been (Married) previously?If Yes, please describeWhen?How Long?When?How Long?EducationHighest grade level completed:Degree obtained, If applicable:Did you have any disciplinary problems in school?If yes please explain:Were you considered hyperactive/ADHD in school?If yes, were you/are on any medication?What kinda grades did you get in school?Have you served in the military?If yes Please describe briefly:What of discharge (separation) did you get?Have you ever been arrested?If yes please describe:Have you ever been abused?VerballyEmotionallyPhysicallySexuallyNegelectedNot abusedPlease describe:Substance AbuseAlcoholAlcoholDo you drink alcohol?If yes, age of first useHow much do you drink?How often do you drink?Have you ever passed out from drinking?How often?Have you ever blacked out from drinking?How often?Have you ever had the "shakes"?How often?Have you ever felt you should cut down on your drinking/drug use?Have you ever felt you should cut down on your drinking/drug use?Have people annoyed you by criticizing your drinking/drug use?Have you ever felt bad or guilty about your drinking/drug use?Have you ever drank/used drugs in the morning to steady your nerves or relieve a hangover?Do you use tobacco?If yes, how often?Other DrugsSelect DrugMarijuanaCocaineCrackHeroinMethamphetamineEcstasyEver Used?Age at 1st useTime since last useApprox use in last 30 daysIs there anything else you would like us to know about you?Additional InformationAre you currently employed?YesNoCurrently a student?YesNoIf yes, what is your current employment situation and name of school?Do you enjoy your work? Is there anything stressful about your current work?Do you consider yourself to be religious?YesNoIf yes, describe your faith or belief:What do you consider to be some of your strengths?What do you consider to be some of your weaknesses?How and with whom do you spend leisure time?In your own words, describe the current problems as you see them:How long has this been going on?IF you had any difficulties in the past, what have you done to cope? Was it helpful?What would you like to accomplish out of your time in therapy?NameDate:Signature:Patient Consent Form For Christian CounselingFull Name:Address:DOB:Email:Phone/Cell:Please Select:ParentGuardianSelfDateSignature:Do you have medical insurance?YesNoInsurance provider?DetailsRequest for records: $ 25.00 (minimum of 6-10 sessions) Regular Therapy Services!- Sessions are 45 minutes- 1 hourSubmit Application
