1.E. Client History

Being as detailed as possible helps your intake process.

Client History

Client First Name

Client Last Name

Date of Birth

Mobile Number

You may get appt reminder texts at this number

May we text you at this mobile number?

Yes No

Email address

Street Address

Address 2

Apartment, Suite, Building Number

City

State

Zip Code

If Minor - Client Guardian(s)

Client Sex

Male Female

Insurance Company

PHP, BCBSM, Cofinity, McLaren etc.

Plan Name

Will be on your card

Insurance Type

Commercial

Employer or Self Purchased

Medicare Medicaid

Subscriber ID Number

Group Number

Subscriber Name

Name of Person on Insurance Card

Relationship to Client

Guardian, Parent, Spouse, Self

Subscriber Address

Subscriber Address 2

Subscriber City

Subscriber State

Subscriber Zip Code

Subscriber Phone Number

Subscriber Sex

Male Female

Subscriber Date of Birth

How many times have you been married?

How many children do you have?

Who do you live with?

What are the major problems in your present household? (living conditions, relationship problems, financial problems, social problems, etc.)

If you are spiritual or religious what denomination or values do you prefer?

What is the reason you would like therapy? (What are your symptoms, when did they start, how long do they last, how often do they happen?)

How many psychotherapists/counselors have you seen in the past for this problem and related problems?

Are you presently in psychotherapy/counseling with anyone?

Yes No

Please list any past or prior diagnoses that you are aware of.

Depression, anxiety, bipolar, panic attacks

How many psychiatrists have you seen for medication management?

What has your experience with medication been so far?

Please list any

Please list any medications you have been prescribed for psychiatric reasons in the past.

examples may be Lexapro, seroquel, venlafaxine, xanax

Have you been hospitalized for psychiatric reasons in the past?

Yes No

How many times have you been hospitalized for psychiatric reasons?

Do you have a violent history?

Yes No

Have you ever attempted suicide in the past?

Yes No

Do you physically hurt yourself?

Yes No

Do you have thoughts of seriously harming yourself or others now?

Yes No

Are you or have you been an abuser or victim of abuse?

Yes No

If yes, please explain.

Have you had significant trauma in your life? Natural Disaster, accidental, abuse, violence, domestic violence etc.

Yes No

If yes, please explain.

Were you physically, emotionally or sexually abused as a child?

Yes No

Please list family members who have had a history of psychiatric illness and what their diagnosis was.

Has a family member ever committed suicide?

Yes No

Medical History

Please list any other medical conditions or concerns you have at this time.

Who is your Primary Care Physician?

Have you had a physical in the last 12 months?

Yes No

Please list other doctors you see regularly, and what you see them for.

Current list of Medications - Please be thorough

Please include supplements and vitamins as well

Substance Use History

Have you ever had treatment for substance abuse?

Yes No

If yes, please check what kind of treatment you received

Inpatient

Intensive Outpatient

Outpatient

Detox

Social History

Please describe any significant relationships outside of your family

Best friends, business partners, childhood friends, etc.

Who is supportive of you at this time?

Have there been any deaths in your family or support system in the last five years?

Yes No

If yes, please explain.

Are you facing any legal difficulties at this time?

Yes No

If yes, please explain your legal difficulties.

Have you ever been arrested?

Yes No

If you have been arrested please list dates, charges, convictions and sentences.

Are you currently on probation or parole?

Yes No

Please list the last five jobs you've had.

Strengths/Limitations

Please list what you believe to be your strengths and abilities

Please list what you believe to be holding you back.

What are some of your needs?

Do you have any specific preferences for your care?

Is there anything you are worried about regarding starting therapy?

Your information will be encrypted.

Mental Health, Trauma and Addiction Services

Telephone 517-667-0061, Fax 517-507-4888
www.guidetopersonalsolutions.com
GPSlansing
1801 E Saginaw St Suite 1, Lansing, Michigan, 48912-2326