Adult Self-Report

Tzippy Farhy Psychotherapy, LLC

Please correct the errors described below.

Please describe the main difficulty that has brought you to see me:

Employment

Employer

Work phone

Work address

Occupation

Length of time with this employer

Please indicate any restrictions on calls

Present Relationships

How do you get along with your spouse or partner?

How do you get along with your children?

Past Psychological / Psychiatric Treatment

Have you ever received psychological, psychiatric, drug or alcohol treatment, or counseling services?

Yes No

Type of treatment

Inpatient Outpatient Both

When

From whom

For what

Results

Have you ever taken medications for psychiatric or emotional problems?

Yes No

When

From whom

For what

Results

Social History

Siblings (please list your siblings and their ages)

List of Symptoms

Please check any of the following that have been bothering you lately.

Please check any of the following that have been bothering you lately

abused as child

agoraphobia

alcohol use

ambition

anger

anxiety

appetite

being a parent

bowel trouble

career choices

children

compulsions

compulsivity

concentration

confidence

depression

divorce

drug use/abuse

eating problem

education

energy (high/low)

extreme fatigue

fears

fetishes

finances

friends

guilt

headaches

health problems

inferiority feelings

insomnia

loneliness

making decisions

marriage

memory

my thoughts

nervousness

nightmares

obsessive thinking

overweight

painful thoughts

panic attacks

phobias

relationships

sadness

self-esteem

separation

sexual problems

short temper

shyness

sleep

stress

suicidal thoughts

work

Impact on Daily Life

Please indicate how the issue(s) for which you are seeking treatment are affecting the following areas of your life:

Marriage / Relationship

1 - No effect 2 - Little effect 3 - Some effect 4 - Much effect 5 - Significant effect Not Applicable

Family

1 - No effect 2 - Little effect 3 - Some effect 4 - Much effect 5 - Significant effect Not Applicable

Job / school performance

1 - No effect 2 - Little effect 3 - Some effect 4 - Much effect 5 - Significant effect Not Applicable

Friendships

1 - No effect 2 - Little effect 3 - Some effect 4 - Much effect 5 - Significant effect Not Applicable

Financial situation

1 - No effect 2 - Little effect 3 - Some effect 4 - Much effect 5 - Significant effect Not Applicable

Physical health

1 - No effect 2 - Little effect 3 - Some effect 4 - Much effect 5 - Significant effect Not Applicable

Anxiety level / nerves

1 - No effect 2 - Little effect 3 - Some effect 4 - Much effect 5 - Significant effect Not Applicable

Mood

1 - No effect 2 - Little effect 3 - Some effect 4 - Much effect 5 - Significant effect Not Applicable

Eating habits

1 - No effect 2 - Little effect 3 - Some effect 4 - Much effect 5 - Significant effect Not Applicable

Sleeping habits

1 - No effect 2 - Little effect 3 - Some effect 4 - Much effect 5 - Significant effect Not Applicable

Sexual functioning

1 - No effect 2 - Little effect 3 - Some effect 4 - Much effect 5 - Significant effect Not Applicable

Alcohol / drug use

1 - No effect 2 - Little effect 3 - Some effect 4 - Much effect 5 - Significant effect Not Applicable

Ability to concentrate

1 - No effect 2 - Little effect 3 - Some effect 4 - Much effect 5 - Significant effect Not Applicable

Ability to control anger

1 - No effect 2 - Little effect 3 - Some effect 4 - Much effect 5 - Significant effect Not Applicable

Substance Use

Do you currently consume alcohol?

Yes No

On average, how many drinks per occasion do you consume?

How many days per week do you consume alcohol?

Do you have a history of problematic use of alcohol?

Yes No

Have family members or friends expressed concern about your drinking?

Yes No

Do you currently use non-prescribed drugs or street drugs?

Yes No

Do you have a history of problematic use of prescription or non-prescription drugs?

Yes No

Do you have a family history of alcohol or drug problems?

Yes No

If yes, please describe

Other

Is there anything else that is important for me as your therapist to know about that you have not written about on any of these forms?

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