Last active
February 16, 2017 17:28
-
-
Save Ethan826/24dd8ecd936848df3c3027fa56893ccb to your computer and use it in GitHub Desktop.
This file contains bidirectional Unicode text that may be interpreted or compiled differently than what appears below. To review, open the file in an editor that reveals hidden Unicode characters.
Learn more about bidirectional Unicode characters
\documentclass[12pt]{article} | |
\title{Madigan Kent, LCSW\\Intake Paperwork} | |
\date{} | |
\author{} | |
\newcommand{\signatureblock}{ | |
\begin{table}[!ht] | |
\begin{tabularx}{\textwidth}{XlX} | |
~ & ~ & ~ \\ | |
~ & ~ & ~ \\\cline{1-1}\cline{3-3} | |
\small\textit{Client Signature} & ~ & \small\textit{Therapist Signature} \\ | |
~ & ~ & ~ \\ | |
~ & ~ & ~ \\\cline{1-1}\cline{3-3} | |
\small\textit{Date} & ~ & \small\textit{Date} \\ | |
\end{tabularx} | |
\end{table} | |
} | |
\usepackage{libertine,geometry,microtype,graphicx,tabularx,latexsym,multicol,enumitem} | |
\begin{document} | |
\maketitle | |
\section{Informed Consent \& Agreement for Services} | |
This document is intended to provide you important information regarding your | |
treatment. Please read it entirely and carefully and be sure to ask me any | |
questions you may have regarding its contents. | |
\subsection{Information about Your Therapist} | |
I am a Licensed Clinical Social Worker (LCSW). I received my BA from Columbia | |
University and my MSW from San Diego State University. I completed three years | |
of post-graduate training in Bioenergetic Analysis, a form of psychotherapy | |
that combines talk therapy with an understanding of the importance of the | |
body~-- and the energy that underlies both body and mind~-- in maintaining | |
psychological and emotional health. I have completed the three-year Somatic | |
Experiencing training program, focused on body-centered trauma treatment | |
interventions. I am also receiving ongoing training in Emotionally Focused | |
Therapy (EFT) for Couples. Please feel free to ask me questions regarding my | |
education, specializations, experience and professional orientation. | |
\subsection{Fees and Insurance} | |
My professional fee has already been discussed with you, as well as how | |
arrangements may be made for payment. A therapeutic hour is 54--60 minutes in | |
length and fees are payable at the time services are rendered. | |
\subsection{Confidentiality} | |
All communications between you and me will be held in strict confidence with | |
the following exceptions: | |
\begin{enumerate} | |
\item You have signed an authorization allowing me to disclose information | |
\item You are in present danger of harming yourself, or committing physical | |
violence to another person | |
\item You are in court ordered therapy; or your records are petitioned by the | |
court | |
\item There is an issue of child, elder, or dependent adult abuse | |
\item In addition, a federal law known as The Patriot Act of 2001 requires | |
therapists (and others) in certain circumstances, to provide FBI agents | |
with books, records, papers, documents and other items and prohibits the | |
therapist from disclosing to the patient that the FBI sought or obtained | |
the items under the Act. | |
\end{enumerate} | |
If you participate in marital or family therapy, I will not disclose | |
confidential information about your treatment unless all person(s) who | |
participated in the treatment with you provide their written authorization to | |
release. (In addition, I will not disclose information communicated privately | |
to me by one family member, to any other family member without written | |
permission.) | |
\subsection{Appointment Scheduling and Cancellation Policies} | |
Sessions are typically scheduled to occur one time per week at the same time | |
and day if possible. Sometimes, I may suggest a different amount of therapy | |
depending on the nature and severity of your concerns. Your consistent | |
attendance greatly contributes to a successful outcome. In order to cancel or | |
reschedule an appointment, I would appreciate the courtesy of twenty-four hours | |
notice; otherwise you will be charged your customary fee for that session, | |
barring emergencies of course. If you are using insurance and cancel without | |
notice, you will be charged the full insurance fee, not just the co-pay. | |
\subsection{Therapist Availability/Emergencies/General Policies} | |
I would be happy to respond to any questions or needs you may have in between | |
visits and during my normal working hours. However, I will attempt to keep | |
these contacts brief as most important issues are better addressed within the | |
context of a regular face-to-face session. I check my voicemail several times | |
throughout the day and will return your call as soon as possible. However, if | |
you should have a mental health emergency and are unable to reach me, please | |
call 911. | |
\subsection{About the Therapy Process} | |
It is my intention to provide services that will assist you in reaching your | |
goals. Based upon the information you share, I will provide recommendations to | |
you regarding your treatment and you have the right to agree or disagree with | |
my recommendations. I believe that therapists and clients are partners in the | |
therapeutic process. Periodically, I will provide feedback to you regarding | |
your progress and invite your participation in this discussion. Due to the | |
varying nature and severity of problems and the individuality of each patient, | |
I am unable to predict the length of your therapy or to guarantee a specific | |
outcome or result. | |
\subsection{Termination of Therapy} | |
The length of your treatment and the timing of the eventual termination of your | |
treatment depend on the specifics of your treatment plan and the progress you | |
achieve. It is a good idea to plan for your termination, in collaboration with | |
me. We will discuss a plan for termination as you approach the completion of | |
your treatment goals. | |
You may discontinue therapy at any time. If you or I determine that you are not | |
benefiting from treatment, either of us may elect to initiate a discussion of | |
your treatment alternatives. These alternatives may include, among other | |
possibilities, referrals, changing your treatment plan, or terminating your | |
therapy. | |
Your signature indicates that you have read this agreement carefully and | |
understand its contents. Please ask me to address any questions or concerns | |
that you have about this information before you sign! | |
\signatureblock | |
\pagebreak | |
\section{Notice of Privacy Practices and Client Rights} | |
This notice describes how treatment information about you may be used and | |
disclosed and how you can get access to this information and your rights as a | |
client. Please review it carefully. Madigan Kent, LCSW, has been and will | |
always be totally committed to maintaining clients’ confidentiality. I will | |
only release healthcare information about you in accordance with federal and | |
state laws and ethics of the social work profession. | |
\subsection{Right to Privacy} | |
Health care providers are required by federal and state law to maintain the | |
privacy of your treatment information. We are also required to give you notice | |
about our privacy practices, our legal duties, and your rights concerning your | |
treatment information. I must follow the privacy practices that are described | |
while they are in effect (they went into effect April 14, 2003). I reserve the | |
right to change my privacy practices and the terms of this notice at any time, | |
provided such changes are permitted by applicable law. You may request a copy | |
of the notice at any time from me. | |
\subsection{Use and Disclosures of Treatment Information} | |
I will use information about your health care to provide you with treatment, to | |
arrange payment for my services, and in conjunction with other health care | |
providers, organizations, and professionals. The information privacy practices | |
in this notice will be followed by any associate involved in your care and any | |
business associate with whom I share health information. | |
Use and disclosure of your health information is for the purpose of providing | |
services. Providing treatment services, collecting payment and conducting | |
healthcare operation are necessary activities for quality care. State and | |
federal laws allow me to use and disclose your health information for these | |
purposes: | |
\paragraph{For treatment.} I may need to use or disclose health information | |
about you to provide, manage, or coordinate your care or related services. This | |
could include consultants and potential referral sources. | |
\paragraph{For payment.} I may use and disclose your treatment information to | |
obtain payment for services I provide you, including~-- but not limited | |
to~-- verifying insurance coverage and/or benefits with your insurance carrier, to | |
process your claims as well as information needed in connection with billing | |
and collection activities. I may bill the person in you family who pays for | |
your insurance. | |
\paragraph{Healthcare operations.} I may need to use information about you to | |
review our treatment procedures and business activity. Information may be use | |
for certification, compliance and licensing activities. | |
\paragraph{Scheduling appointments.} I may use your phone numbers to call you | |
and leave messages to schedule or remind you of appointments. | |
\paragraph{Legal proceedings.} I may disclose information in response to a court | |
or administrative order, subpoena, discovery request, or other lawful process | |
under certain circumstances. | |
\subsection{Other Uses or Disclosures of Your Information Which Do Not Require | |
Consent} | |
There are some instances where we may be required to use and disclose | |
information without your consent. I am mandated by Illinois State Law to report | |
any information reported to me regarding any physical or sexual abuse of a | |
minor or elder. This information will be reported to Department of Children and | |
Family Services as well as other appropriate authorities. | |
I may also disclose information to appropriate authorities if I reasonably | |
believe that you are a possible victim of abuse, neglect, or domestic violence | |
or the possible victim of other crimes. I may disclose information to the | |
extent necessary to protect your health or safety, or the health or safety of | |
others. I may also share information with law enforcement if a crime is | |
committed on the office premises or against myself or as required by law. | |
I will not disclose your treatment information if that disclosure is prohibited | |
or significantly limited by other applicable law. | |
\subsection{Your Client Rights} | |
\paragraph{You have right to request how we contact you.} | |
It is my normal practice to communicate with you about health matters such as | |
appointment reminders, etc. at your home address and daytime phone number you | |
gave when you scheduled your appointment. Sometimes I may leave messages on | |
your voicemail. You have the right to request that I communicate with you in a | |
different way. | |
\begin{table} | |
\begin{tabular}{lp{0.5\textwidth}} | |
May I contact you at home? & ~ \\\cline{2-2} | |
May I contact you at work? & ~ \\\cline{2-2} | |
May I contact you by cell phone? & ~ \\\cline{2-2} | |
Where may I contact you? & ~ \\\cline{2-2} | |
\end{tabular} | |
\end{table} | |
\paragraph{You have the right to release you treatment records.} | |
You may consent in writing to release your records to others. You have the | |
right to revoke this authorization, in writing, at any time. However, a | |
revocation is not valid to the extent that I have acted in reliance on such | |
authorization. | |
\paragraph{You have the right to inspect and copy your treatment and billing | |
records.} You have the right to inspect and obtain a cop of your information | |
contained in my treatment records. To request access to your billing or health | |
information, you must make a request in writing by sending a letter to me at | |
the address above. Under limited circumstances, I may deny your request to | |
inspect and copy. If you request a copy of any information, I may charge a | |
reasonable fee for the costs of copying, mailing, and supplies. | |
\paragraph{You have the right to add information or amend your treatment | |
records.} If you feel that information contained in you treatment record is | |
incorrect or incomplete, you may request me to add information to amend the | |
record with an explanation of why the information should be changed. I will | |
make a decision on your request within 60 days. Under certain circumstances, I | |
may deny your request to add or amend information. If I deny your request, you | |
have a right to file a statement that you disagree. Your statement and my | |
response will be added to your record. To request an amendment, you must make | |
your request in writing by sending a letter to me at the address above. | |
\paragraph{You have the right to an accounting of disclosures.} You have the | |
right to receive a list of instances in which I disclosed your information for | |
purposes other than treatment, payment, or those disclosures you have | |
authorized in writing, such as, if any, child or elder abuse, disclosures | |
related to suicidal or homicidal threats, and disclosures to the U.S. Dept of | |
Human Services to evaluate compliance. | |
\paragraph{You have the right to request restrictions on uses and disclosures | |
of your health.} You have the right to request restrictions on uses and | |
disclosures of your treatment information for the purposes of treatment, | |
payment, or healthcare operations. You request must be submitted in writing to | |
the address listed above. I am not required to allow your request. If I do | |
agree with the request, I will comply with it except to the extent that | |
disclosure has already occurred or if you are in need of emergency treatment | |
and the information is needed to provide that treatment. | |
\paragraph{You have the right to receive changes in policy.} You have the right | |
to receive upon request any future policy changes secondary to changes in state | |
and federal laws. | |
\subsection{Questions \& Complaints} | |
If you have any questions about this notice or have concerns about your privacy | |
rights, it is my sincere hope that you will feel comfortable sharing them with | |
me. | |
If you believe your privacy rights have been violated and wish to file a | |
written complaint with Madigan Kent Therapy, please include as much detail as | |
possible and send it to Madigan Kent, LCSW, 1224 W. Lawrence Ave, Suite 218, | |
Chicago, IL 60625. You may also send a written complaint to the Secretary of | |
the US Department of Health and Human Services 200 Independence Avenue, S.W. | |
Washington, D.C. 20201 or by calling (202) 619-0257. | |
\subsection{Acknowledgement of Receipt of Notice of Privacy Practices} | |
By signing this form, you acknowledge that you have received the Notice of | |
Privacy Practices from Madigan Kent, LCSW. This notice provides information | |
about the ways in which I This notice provides information about the ways in | |
which I may use and disclose your protected health information. I encourage you | |
to read it in full. The Notice of Privacy Practices is subject to change. You | |
may ask me at any time for a copy of the current notice, either in person or by | |
contacting me at the number or addresses above. | |
I acknowledge that I have received the Notice of Privacy Practices. | |
\signatureblock | |
\pagebreak | |
\section{Symptoms and Goals} | |
\subsection{Symptoms checklist} | |
\textsc{Please circle all that apply.} | |
\begin{multicols}{2} | |
\begin{itemize}[noitemsep] | |
\item[] $\Box$\hspace{0.5em}Angry or irritable feelings | |
\item[] $\Box$\hspace{0.5em}Loss of Interest | |
\item[] $\Box$\hspace{0.5em}Hopelessness | |
\item[] $\Box$\hspace{0.5em}Crying spells | |
\item[] $\Box$\hspace{0.5em}Difficulty making decisions | |
\item[] $\Box$\hspace{0.5em}Depression | |
\item[] $\Box$\hspace{0.5em}Suicidal thoughts | |
\item[] $\Box$\hspace{0.5em}Sleep difficulties | |
\item[] $\Box$\hspace{0.5em}Impulses to hurt self or others | |
\item[] $\Box$\hspace{0.5em}Nightmares | |
\item[] $\Box$\hspace{0.5em}Feeling that nothing mattered | |
\item[] $\Box$\hspace{0.5em}Anxiety or nervousness | |
\item[] $\Box$\hspace{0.5em}Violent behavior | |
\item[] $\Box$\hspace{0.5em}Memory loss | |
\end{itemize} | |
\end{multicols} | |
\vspace{1em} | |
\begin{multicols}{2} | |
\begin{itemize}[noitemsep] | |
\item[] $\Box$\hspace{0.5em}Panicky feelings | |
\item[] $\Box$\hspace{0.5em}Fears of particular situations | |
\item[] $\Box$\hspace{0.5em}Avoidance of social situations | |
\item[] $\Box$\hspace{0.5em}Weakness | |
\item[] $\Box$\hspace{0.5em}Fainting spells | |
\item[] $\Box$\hspace{0.5em}Mood swings | |
\item[] $\Box$\hspace{0.5em}Disorientation | |
\item[] $\Box$\hspace{0.5em}Obsessive preoccupations | |
\item[] $\Box$\hspace{0.5em}Repeated thoughts | |
\item[] $\Box$\hspace{0.5em}Compulsive behaviors | |
\item[] $\Box$\hspace{0.5em}Easily distracted | |
\item[] $\Box$\hspace{0.5em}Feel that you may lose control | |
\end{itemize} | |
\end{multicols} | |
\vspace{1em} | |
\begin{multicols}{2} | |
\begin{itemize}[noitemsep] | |
\item[] $\Box$\hspace{0.5em}Paranoid feelings | |
\item[] $\Box$\hspace{0.5em}Elevated mood or euphoria | |
\item[] $\Box$\hspace{0.5em}Too much energy | |
\item[] $\Box$\hspace{0.5em}Can’t stop talking | |
\item[] $\Box$\hspace{0.5em}Racing thoughts | |
\item[] $\Box$\hspace{0.5em}Inability to talk | |
\item[] $\Box$\hspace{0.5em}Suspiciousness | |
\item[] $\Box$\hspace{0.5em}Believe your thoughts are controlled | |
\item[] $\Box$\hspace{0.5em}Fear others | |
\item[] $\Box$\hspace{0.5em}Visual or auditory hallucinations | |
\item[] $\Box$\hspace{0.5em}Confusion | |
\item[] $\Box$\hspace{0.5em}Disorganized thoughts | |
\item[] $\Box$\hspace{0.5em}Self-critical | |
\item[] $\Box$\hspace{0.5em}Feel more important than others | |
\item[] $\Box$\hspace{0.5em}Hear voices when no one is there | |
\item[] $\Box$\hspace{0.5em}See things that aren't there | |
\item[] $\Box$\hspace{0.5em}Transmit your thoughts to others without speaking | |
\item[] $\Box$\hspace{0.5em}Hear your thoughts out loud | |
\end{itemize} | |
\end{multicols} | |
\vspace{1em} | |
\begin{multicols}{2} | |
\begin{itemize}[noitemsep] | |
\item[] $\Box$\hspace{0.5em}Difficulty following rules | |
\item[] $\Box$\hspace{0.5em}Difficulty feeling warm to others | |
\item[] $\Box$\hspace{0.5em}Wanting or letting everyone do things for you | |
\item[] $\Box$\hspace{0.5em}Avoiding responsibilities | |
\item[] $\Box$\hspace{0.5em}Difficulty trusting others | |
\item[] $\Box$\hspace{0.5em}Not getting along with people | |
\item[] $\Box$\hspace{0.5em}Trying to be perfect | |
\item[] $\Box$\hspace{0.5em}Selfishness | |
\item[] $\Box$\hspace{0.5em}Being overly sensitive | |
\item[] $\Box$\hspace{0.5em}Use others for personal gain | |
\end{itemize} | |
\end{multicols} | |
\vspace{1em} | |
\begin{multicols}{2} | |
\begin{itemize}[noitemsep] | |
\item[] $\Box$\hspace{0.5em}Nausea/vomiting | |
\item[] $\Box$\hspace{0.5em}Excessive concern over a physical problem | |
\item[] $\Box$\hspace{0.5em}Headaches | |
\item[] $\Box$\hspace{0.5em}Seizures | |
\item[] $\Box$\hspace{0.5em}Shortness of breath | |
\item[] $\Box$\hspace{0.5em}Medical problems | |
\item[] $\Box$\hspace{0.5em}Drug use or addiction | |
\item[] $\Box$\hspace{0.5em}Anorexia (not eating) | |
\item[] $\Box$\hspace{0.5em}Cheating or stealing | |
\item[] $\Box$\hspace{0.5em}Exaggerating physical problems | |
\item[] $\Box$\hspace{0.5em}Exaggerating emotional problems | |
\item[] $\Box$\hspace{0.5em}Recent weight gain (how much?) | |
\item[] $\Box$\hspace{0.5em}Recent weight loss (how much?) | |
\item[] $\Box$\hspace{0.5em}Lack of energy | |
\item[] $\Box$\hspace{0.5em}Use of alcohol | |
\item[] $\Box$\hspace{0.5em}Bulimia (gorging then vomiting) | |
\item[] $\Box$\hspace{0.5em}Physically abusing yourself | |
\end{itemize} | |
\end{multicols} | |
\subsection{Desired results} | |
What are your goals for therapy? | |
\vspace{-1em} | |
\begin{table}[!ht] | |
\begin{tabularx}{\textwidth}{X} | |
~ \\ \hline | |
~ \\ \hline | |
~ \\ \hline | |
~ \\ \hline | |
\end{tabularx} | |
\end{table} | |
\pagebreak | |
\section{Authorization to Obtain/Release Information} | |
I, \rule{5em}{0.5pt} hereby authorize Madigan Kent, Licensed Clinical Social | |
Worker, to release/obtain information to/from: | |
\begin{table}[!ht] | |
\begin{tabularx}{\textwidth}{XXX} | |
~ & ~ & ~ \\ | |
~ & ~ & ~ \\ \hline | |
\small\textit{Name} & ~ & ~ \\ | |
~ & ~ & ~ \\ | |
~ & ~ & ~ \\ \hline | |
\small\textit{Address} & ~ & ~ \\ | |
~ & ~ & ~ \\ | |
~ & ~ & ~ \\ \hline | |
\small\textit{City} & \small\textit{State} & \small\textit{Zip} \\ | |
~ & ~ & ~ \\ | |
~ & ~ & ~ \\ \hline | |
\small\textit{Phone} & ~ & ~ \\ | |
\end{tabularx} | |
\end{table} | |
\noindent This information will be released for the purpose of case | |
consultation and/or \rule{10em}{0.5pt}. | |
I understand that I may revoke this consent to release/obtain information at | |
any time, except to the extent that action has already been taken for the | |
purpose(s) specified above. | |
This consent will be valid from \rule{10em}{0.5pt} to \rule{10em}{0.5pt}. You | |
may receive a copy of this authorization upon request. | |
\signatureblock | |
\pagebreak | |
\section{Authorization Release for Permission to Record and for Use of Recorded Material} | |
Video and audio recording are commonly used for consultation, training and | |
research in couple therapy. In order to record your session I need your written | |
consent. The recording of sessions will likely enhance the effectiveness of | |
your treatment, but is not required. You may decline to have sessions recorded. | |
\paragraph{Confidentiality.} For any of the uses agreed to below, the strictest | |
confidentiality will be maintained, and there will be no sharing of the | |
recorded material beyond the limits specified below. Except for your first | |
names and your voice and/or image on the recordings, there will be no | |
information that could identify you. The recording will never knowingly be | |
shared with anyone who knows you. Mental health professionals who may view or | |
hear recorded material of your session (if permission is given here) are bound | |
by law and by code of ethics to the same obligation to protect your | |
confidentiality. Except as noted below, the existence of this recording will | |
not be discussed with anyone at any time. | |
\begin{table}[!ht] | |
\begin{tabularx}{\textwidth}{|l|l|X|} | |
\hline | |
Video \& Audio & Audio Only & How the recorded material may be used \\\hline | |
~ & ~ & \textsc{Session Review Only.}\hspace{0.5em} The recording may be reviewed privately by Madigan Kent prior to the subsequent session. IT will not be kept beyond the subsequent session and no recording will be kept beyond the conclusion of treatment. \\\hline | |
~ & ~ & \textsc{Consultation.}\hspace{0.5em} The recording may be shared with the clinical consultant who has been engaged to provide expert clinical consultation regarding the therapy process. The consultation is a vital source of professional development and accountability; it provides additional clinical expertise as a resource to your treatment and increases its effectiveness. \\\hline | |
~ & ~ & \textsc{Training.}\hspace{0.5em} A brief recording excerpt may be used by Madigan Kent in the training of couple therapists to demonstrate concepts and techniques of treatment. No information, which could identify you, beyond the content of the tape, will be shared. \\\hline | |
\end{tabularx} | |
\end{table} | |
\paragraph{Other Conditions (specify).} | |
~\vspace{3em} | |
\paragraph{Freedom to withdraw consent} We understand that we may withdraw | |
previously granted consent at any time without giving a reason, and that this | |
will not affect our treatment or relationship with our therapist in any way. | |
We give our permission to Madigan Kent, LCSW to video/audio (circle one) record | |
our couple therapy sessions for the purposes indicated above. | |
\signatureblock | |
\pagebreak | |
% \section{Client Information Form} | |
% \begin{table}[!h] | |
% \begin{tabularx}{\textwidth}{XXXXXXXXXXXX} | |
% Date & \multicolumn{5}{l}{~} & SSN & \multicolumn{5}{l}{~} \\\cline{2-6}\cline{8-12} | |
% \multicolumn{7}{l}{~} & \multicolumn{5}{c}{\small\textit{(Insurance only)}} \\ | |
% ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ \\ | |
% ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ \\\cline{1-12} | |
% \multicolumn{4}{c}{Name} & \multicolumn{4}{c}{Birth Date} & \multicolumn{4}{c}{Age} \\ | |
% ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ \\ | |
% ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ \\ | |
% \multicolumn{2}{l}{Home Address} & \multicolumn{10}{l}{~} \\\cline{3-12} | |
% & & & \multicolumn{3}{c}{Street} & \multicolumn{3}{c}{City} & \multicolumn{3}{c}{Zip Code} \\ | |
% & & & & & & & & & & & \\ | |
% & & & & & & & & & & & \\\cline{1-12} | |
% \multicolumn{4}{c}{Home Ph \#} & \multicolumn{4}{c}{Work Ph \#} & \multicolumn{4}{c}{Other} \\ | |
% & & & & & & & & & & & \\ | |
% \multicolumn{2}{l}{Marital Status:} & \multicolumn{2}{c}{Single\hspace{1em}\Box} & \multicolumn{2}{c}{Married\hspace{1em}\Box} & \multicolumn{2}{c}{Separated/Divorced\hspace{1em}\Box} & \multicolumn{2}{c}{Widowed\hspace{1em}\Box} & \multicolumn{2}{c}{Live-In\hspace{1em}\Box} \\ | |
% ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ \\ | |
% ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ \\ | |
% \multicolumn{2}{l}{Employer} & \multicolumn{10}{l}{~} \\\cline{3-12} | |
% \multicolumn{3}{l}{~} & \multicolumn{3}{c}{Name of Company} & \multicolumn{3}{c}{Address} & \multicolumn{3}{c}{Phone} \\ | |
% ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ \\ | |
% ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ \\ | |
% \multicolumn{2}{l}{Referred by} & \multicolumn{10}{l}{~} \\\cline{3-12} | |
% & \multicolumn{11}{c}{Source/Name} \\ | |
% ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ \\ | |
% ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ \\ | |
% \multicolumn{2}{l}{Emergency Contact} & \multicolumn{10}{l}{~} \\\cline{3-12} | |
% \multicolumn{2}{l}{~} & \multicolumn{2}{c}{name} & \multicolumn{4}{c}{address} & \multicolumn{2}{l}{phone} & \multicolumn{2}{l}{relationship} \\ | |
% ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ \\ | |
% ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ \\ | |
% \multicolumn{2}{l}{Insurance} & \multicolumn{10}{l}{~} \\\cline{3-12} | |
% \multicolumn{3}{l}{~} & \multicolumn{3}{c}{Name} & \multicolumn{3}{c}{Policy \#} & \multicolumn{3}{c}{Insured's name} \\ | |
% ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ \\ | |
% ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ \\ | |
% \multicolumn{3}{l}{Insurance Billing Address} & \multicolumn{9}{l}{~} \\\cline{4-12} | |
% \multicolumn{3}{l}{~} & \multicolumn{3}{c}{City} & \multicolumn{3}{c}{State} & \multicolumn{3}{c}{Provider Phone \#} | |
% \end{tabularx} | |
% \end{table} | |
\subsection{Treatment History} | |
\begin{enumerate} | |
\item Have you ever seen a mental health professional? If so, please | |
describe: who, when, and for what problem.\vspace{5em} | |
\item Please | |
describe any psychiatric hospitalizations: when, where, and for what | |
problem.\vspace{5em} | |
\end{enumerate} | |
\subsection{Childhood History} | |
\begin{enumerate} | |
\item Where did you grow up?\vspace{3em} | |
\item Did you move often? If so, how | |
many times would you estimate you moved before leaving home?\vspace{3em} | |
\item How old were you when you moved away from home, and what were the | |
circumstances?\vspace{3em} | |
\item Who raised you? Please describe if it was someone other than your parents.\vspace{3em} | |
\item Describe your parents' personalities | |
\begin{enumerate} | |
\item Mother\vspace{3em} | |
\item Father\vspace{3em} | |
\end{enumerate} | |
\item How did your parents treat you? | |
\begin{enumerate} | |
\item Mother\vspace{3em} | |
\item Father\vspace{3em} | |
\end{enumerate} | |
\item Describe your parents' marriage.\vspace{3em} | |
\item Circle all of the following circumstances that apply to your parents. | |
\begin{enumerate} | |
\item Separation | |
\item Multiple separations | |
\item Divorce | |
\item Domestic violence | |
\item Mother's remarriage (how many times?) | |
\item Father's remarriage (how many times?) | |
\end{enumerate} | |
\item What are/were your parents' occupations? | |
\begin{enumerate} | |
\item Mother\vspace{3em} | |
\item Father\vspace{3em} | |
\end{enumerate} | |
\item List your siblings and their ages relative to yours.\vspace{3em} | |
\item What level of schooling did you complete?\vspace{3em} | |
\end{enumerate} | |
\subsection{Substance Use} | |
\begin{enumerate} | |
\item Have you ever used street drugs? If so, please name them and at what | |
age you started.\vspace{3em} | |
\item Have you had any problems with these drugs?\vspace{3em} | |
\item How much alcohol do you drink? Please name what, how much and how | |
often.\vspace{3em} | |
\item Do you smoke tobacco? If so, how much?\vspace{3em} | |
\end{enumerate} | |
\subsection{General Health} | |
\begin{enumerate} | |
\item Do you have chronic tension in your body? If so, please describe.\vspace{3em} | |
\item Do you have frequent headaches? If so, have you received a medical | |
explanation for them?\vspace{3em} | |
\item What if any physical exercise do you regularly do? Please describe.\vspace{3em} | |
\item Have you had any traumatic experiences or serious accidents? If so, please describe.\vspace{3em} | |
\item Have you had any major diseases? If so, please describe.\vspace{3em} | |
\item Have you had any major surgeries? If so, please describe.\vspace{3em} | |
\item What if any prescription medicines do you take?\vspace{3em} | |
\item What if any non-prescription medicines, herbs, or other supplements do you take?\vspace{3em} | |
\end{enumerate} | |
\subsection{Incomplete Sentences} | |
Please complete the following sentences: | |
\begin{enumerate} | |
\item I like | |
\item The happiest time | |
\item I want to know | |
\item Back home | |
\item I regret | |
\item At bedtime | |
\item Men | |
\item The best | |
\item What annoys me | |
\item People | |
\item A mother | |
\item I feel | |
\item My greatest fear | |
\item In high school | |
\item I can't | |
\item Sports | |
\item When I was a child | |
\item My nerves | |
\item Other people | |
\item I suffer | |
\item I failed | |
\item The future | |
\item My mind | |
\item Reading | |
\item I need | |
\item Marriage | |
\item I am best when | |
\item Sometimes | |
\item What pains me | |
\item I have | |
\item This place | |
\item I am very | |
\item The only trouble | |
\item I wish | |
\item My father | |
\item I secretly | |
\item I | |
\item Dancing | |
\item My greatest worry is | |
\item Most women | |
\end{enumerate} | |
\pagebreak | |
\end{document} |
Sign up for free
to join this conversation on GitHub.
Already have an account?
Sign in to comment