New Leaf Counseling Services

NewLeafCounselingServicesBiographical Information – Intake FormPlease fill out this biographical background form as completely as possible.It will help me in our work together. Information is confidential as outlinedin the Office Policy form and the HIPAA Notice of Privacy Practices. If youdo not desire to answer any question, merely write, "Do not care toanswer." Please print or write clearly and bring it with you to the firstsession.NAME: DateMALE/FEMALE:Date of BirthAGE: Place of Birth Marital Status:CURRENT HOME ADDRESS:TELEPHONES: H: Cell: Work/Off: Fax:FOR ROUTINE MESSAGES: Phone #Email:FOR CONFIDENTIAL/PRIVATE MESSAGES: Phone #PERSON & PHONE NO. TO CALL IN EMERGENCY:REFERRAL SOURCE:OCCUPATION (former, if retired):PRESENTING PROBLEM (be as specific as you can: when did it start, how does itaffect you.):

Estimate the severity of above problem: Scale 1-10 ( 10 is the most es?Alcohol?Sedatives/Sleep h?Shopping?Other?PAST/PRESENT DRUG/ALCOHOL/PRESCRIPTION USE/ABUSE (AA, NA, Rehab, IOP,In-patient hospitalization treatments):PAST/PRESENT INTENSIVE OUT PATIENT TREATMENT:DID YOU SERVE IN THE ARMED FORCES?WHERE?WHEN?HOW LONG?DID YOU EXPERIENCE TRAUMA:SUICIDE ATTEMPT/S or VIOLENT BEHAVIOR (describe: ages, reasons,circumstances, how, etc.)CURRENT: Marital status: Live with someone:Name:Years Together: Is it OK for us to consult with your partner?(We will require an Authorization Form)PRESENT SPOUSE/PARTNER/SIGNIFICANT OTHER:Education:

Occupation:Does your partner have any addictions?PAST & PRESENT MARRIAGE/S (names, years together, and statement about thenature of the relationship(s), i.e., friendly, distant, physically/emotionally abusive,loving, hostile.):FOR FEMALES OR COUPLES:Number of Pregnancies:Live Births:Difficulties with Pregnancies: Yes NoIf Yes, Please ExplainPremature Births:Miscarriages: Ectopic: Stillbirth:Abortion(s):Did You Experience Post-Partum Depression?Did You Experience Post-Partum Psychosis?Did You Seek Treatment?Therapy?Support Groups?CHILDREN/STEP/ (names/ages/sex/where they reside & brief statement on yourrelationship.)1.2.3.

4.WHERE YOU ADOPTED?AT WHAT AGE?FAMILY MEDICAL HISTORY : (Mood disorders/addictions/suicide illness that runs inthe family: e.g., cancer, epilepsy, etc): Who?PARENTS/STEPPARENTS (Name/age or year of death/cause of death, occupation,personality, how did s/he treat you, brief statement about the relationship.):Father:Mother:Step-parents:SIBLINGS (name/age, if deceased: age and cause of death and brief statementabout the relationship.):CURRENT MEDICAL DOCTOR(S) PSYCHIATRIST(S) (name/phone):PAST/PRESENT MEDICAL CARE (major medical problems, surgeries, accidents, falls,illness, etc.):

SPECIFY MEDICATION you are presently taking and for what.PRINT clearly:RELIGION & SPIRITUALITY:PAST/PRESENT PSYCHOTHERAPY (specify: month year(s) (beginning—end),estimated no. of sessions, name, degree, phone & address, initial reason for therapy,Individual/Couple/Family, medication, brief description of the relationship and howhelpful it was, and how/why it ended):1.2.USE OTHER SIDE OF PAGE TO ADD MORE INFORMATION ABOUTPSYCHOTHERAPISTS, IF NEEDED.DESCRIBE YOUR CHILDHOOD, IN GENERAL (Relationships with parents, siblings,others, school, neighborhood, relocations, any school/behavioral/problems,abusive/alcoholic parent):Favorite ChildhoodMemory:Worst Childhood Memory:Who were you closest to/gave you comfort/unconditional love when you were achild?

Have you ever been the victim of nger Rape?Did you receive psychological treatment for the above abuse?IF PARENTS DIVORCED: Your age at the time: .Describe how it affected you at the timeARE YOU INVOLVED IN ANY CURRENT OR PENDING CIVIL OR CRIMINALLITIGATION/S, LAWSUIT/S OR DIVORCE OR CUSTODY DISPUTE/S? (if you answerYes, please explain):What gives you the most joy or pleasure in your life?What are your main worries and fears?What are your most important hopes or dreams?What are your goals for treatment?Signature:Growth Brings Positive Change.Date:

Estimate the severity of above problem: Scale 1-10 ( 10 is the most severe) ADDICTIONS: Marijuana? Opiates? Alcohol? Benzodiazepines?