PsychotherapyForWomen.com. Vicki Bonnell, LCSW vickibonnell2@gmail.comPATIENT INTAKE FORM 3
FAMILY HISTORY ( Medical/Psychiatric Diagnoses, Substance Abuse or Self- Injury/Suicide):
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PAST PSYCHIATRIC HISTORY
Outpatient Treatment ( ) Yes ( ) No If yes with whom, how long, reason for treatment
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Impatient Treatment( ) Yes ( ) No If yes describe for what reason you were hospitalized, where and for how long?
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Family/Childhood History:
Birth Place/Date___________________________________________________________________
Where did you grow up?______________________________________________________________
Parents/Caregivers_________________________________________________________________
Siblings Names and Ages_____________________________________________________________
Did your parents divorce? (Yes) (No) Your age at their divorce____ you lived with_____________________
Trauma History:
Have you endured verbal, emotional, sexual, physical abuse or experienced neglect? ( ) Yes ( ) No
A more detailed assessment of childhood history will take place during evaluation session.
Educational:
Highest level of education and degree obtained______________________
Are you currently working and or attending school? (Yes) (No)
if so please explain_______________________________________________________
Current Family and Relationship History:
Are you currently ( ) Married ( ) Living with partner ( ) Divorced ( ) Widowed and for how long?_________
Do you have children, and if so list ages and gender_______________________________________
Legal: Have you ever been arrested?_______________
Do you have any pending legal problems?______________________________________________