New Clients Welcome to LifeWorks Counseling! Thank you for filling out this form for new patients. It will help us serve you. Basic InformationDate Patient Nate Social Security Number Date of Birth Gender MaleFemaleEthnicity Contact InfoHome Address Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountryHome Phone Number May we leave a message on your Home Phone? YesNoWork Phone Number May we leave a message on your Work Phone? YesNoMobile Phone Number May we leave a message on your Mobile Phone? YesNoIf the above patient is a minor complete the following:Address of Guardian Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountryGuardian's Home Phone May we leave a message on Guardian's Home Phone? YesNoGuardian's Work Phone May we leave a message on Guardian's Work Phone? YesNoGuardian's Mobile Phone May we leave a message on Guardian's Mobile Phone? YesNo Insurance InfoIf you will be using insurance to cover your sessions or a portion of the cost please complete the following and allow us to make a photocopy of your insurance card: Primary Insurance Company Secondary Insurance Company (if applicable): Referral SourceWho referred you to our office, or how did your learn about our practice? Emergency Contact InformationIn case of an emergency, who should we contact? Name Relationship Address Phone Number History InformationWho is providing the history information? The patientThe patient's guardianOtherPlease describe the current complaint or problem as specifically as you can, in your own words. How long have you experienced this problem, or when did you first notice it? What stressors may have contributed to the current complaint or problem? Check all words/phrases that describe what you are experiencing and explain if possible. Substance abuse/dependenceAddiction (internet, porn, shopping, exercise, gaming, gambling, etc.)Depression/Sad/Down feelingsHigh/Low energy levelAngry/IrritableLoss of interest in activitiesDifficulty enjoying thingsCrying spellsDecreased motivationWithdrawing from people/IsolationMood SwingsBlack and white thinking/All or nothing thinkingNegative thinkingChange in weight or appetiteChange in sleeping patternSuicidal thoughts or plans/Thoughts of hurting yourselfSelf-harm/Cutting/Burning yourselfHomicidal thoughts or plans/Thoughts of hurting othersPoor concentration/Difficulty focusingFeelings of hopelessness/WorthlessnessFeelings of shame or guiltFeelings of inadequacy/Low self-esteemAnxious/Nervous/Tense feelingsPanic attacksRacing or scrambled thoughtsBad or unwanted thoughtsFlashbacks/NightmaresMuscle tensions, aches, etc.Hearing voices/Seeing things not thereThoughts of running awayParanoid thoughts/Thoughts that someone is watching you, out to get you or hurt youFeelings of frustrationFeelings of being cheatedPerfectionismRituals of counting things, washing hands, checking locks, doors, stove, etc./Overly concerned about germsDistorted body image (believe you are heavier or less attractive than others say you are)Concerns about dietingFeelings of loss of control over eatingBinge eating/PurgingRules about eating/Compensating for eatingExcessive exerciseIndecisiveness about careerJob problemsOther: If applicable, please explain any above responses. Previous TreatmentHave you received or participated in previous counseling and/or therapy? YesNoAdditional Information: What did you like/dislike about previous treatment? What did you learn about yourself through previous counseling/treatment that may help you? Is there any type of treatment you would like to continue? Have you had hospital stays for psychological concerns? YesNoAre you currently experiencing thoughts of harming either yourself or someone else? YesNoHave you in the past experienced thoughts of harming either yourself or someone else? YesNo Developmental HistoryAre you aware of any difficulties or complications during the time your mother was pregnant with you? YesNoIf yes, explain: Did you walk, talk, and read on time? YesNoIf no, explain Do you feel you have completed normal life milestones (school, career, marriage, children, etc.) at appropriate times? Are you satisfied at where you are in your life? If not, where would you like to be? Medical HistoryList any current or important past medications. List medication, dose, and your response to the medication. History of serious childhood illnesses: Other health concerns, serious illnesses, conditions, or major operations requiring hospitalization during your life time: Have you experienced any head injuries? YesNoIf yes, did you lose consciousness? YesNoHave you experienced convulsions or seizures? YesNoIf yes, did you also have a fever? YesNoExplain any allergies you have: How would you rate your current physical health? ExcellentVery GoodGoodFairPoorVery PoorWhat was the date of your last physical or routine health “check up?” Do you have a primary care physician? YesNoIf yes, complete the following: Name Address Phone Number Family HistoryBirth Location: Raised by: MotherFatherStep-MotherStep-FatherOther: Relationship with parent figures: (good, fair, poor, close, distant, etc.) Mother: Father: Step-parent: Other: List your siblings and describe your relationship with them. (Include name, age, gender, and nature of relationship) Any history of neglect, and/or physical, verbal, emotional, spiritual, or sexual abuse? Any family history of substance abuse, mental illness, suicide, or violence? Any Additional Family Information: Social HistoryDescribe your relationship with peers and/or friends. How would you describe your social support network? Describe your hobbies/interests: Describe any cultural concerns: Educational HistoryWhen attending school, were you: In regular classesHome studySpecial classesAdvanced classesEver suspendedPlaced in alternative schoolWhat is the highest educational level you have completed? Give any additional important educational information (i.e. Did you like school? Have a learning disability?) Occupational HistoryWhat is your current employment status? Employed Full-TimeEmployed Part-TimeUnemployedSelf-employedStudentOtherAre you satisfied with your employment? If not, why? Marital HistoryWhich best describes your marital status? MarriedNever MarriedWidowedSeparatedDivorcedWhat are the dates of above marital status? (What date were you married, etc) If you are married, please briefly describe nature of your marital relationship: If you are married, which best describes your marital satisfaction? PoorFairGoodGreatPlease list any previous marriages/significant relationships, including current: (Include name, date, and nature of relationship) Do you have children? YesNoIf yes, what is their first name, age, gender, and the nature of relationship? Are there presently any child custody issues involving you or your family? YesNoDoes your family currently have Child Protective Services Involvement? YesNoIf yes please complete the following: Case Worker’s Name: Phone Substance Abuse HistoryAre you currently or have you ever struggled with substance abuse? (alcohol, tobacco, marijuana, caffeine, or other) YesNoIf you answered yes, please complete the following substance abuse section below: Substance? (Alcohol, Marijuana, Cocaine or Crack, Heroin, Amphetamines , Club Drugs (Ecstasy, Inhalants, etc.) , Pain Medication (Oxycontin, Vicodin, etc.), Benzodiazepines , Hallucinogens) Age of First Use? Frequency of Use? (Daily, Weekly, Monthly) Amount Used? How did you use it? (smoked, injected, etc.) Complete the following section if you have ever received treatment for a substance abuse issue. Name of Treatment Program Type of Treatment (Rehab, Intensive Outpatient Program, Partial Hospitalization, Halfway House, Recovery House, Counseling, Methadone, Suboxone) Date of Treatment (Month, Year) Outcome (Any Clean time?) Legal History Do you currently have any pending criminal charges? YesNoAre you on probation? YesNoName of Probation Officer and County Have you ever been arrested/convicted of a crime? YesNoIf yes, please fill out section below List any Arrests/Convictions Date of Arrests/Convictions Outcome (Served time, Community Service, Drug/Alcohol Treatment, etc.) Additional InformationSummarize your goals for counseling/therapy: What expectations do you have for counseling/therapy? Name 5 things you would like to change about yourself. What are your strengths? What are your weaknesses? Is there any additional information that you believe it is important for your counselor to know in order to provide you with the best care possible? For security, please enter any two digitsExample: 12 Press "Submit" to securely send your questionarre to LifeWorks Counseling. Thank you.This box is for spam protection - <strong>please leave it blank</strong>: