"*" indicates required fields Ephesians Professional Counseling CLIENT ASSESSMENT Therapist*Select TherapistBethesda - Leslie MarlerCollege Park - Dianne Fisher-GriffithCollege Park - Belita ProctorCollege Park - Sheila CuomoClient Information Please fill in this section with the Client's information. Name* First Middle Last Birthday* Month Day Year Assessment Date* MM slash DD slash YYYY Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Primary / Cell Phone*Secondary PhoneEmail If Client is a Minor, Parents' or Legal Representative's Name(s):Mother's NameFather's NameClient is:* Male Female Marriage Status*SingleMarriedDivorced / SeparatedWidowedSignificant OtherOtherName of Spouse / Significant OtherPhoneEmergency Contact Information In case of an emergency please provide a person we can contact.Contact Name*Relationship to Client*Primary / Cell Phone*Secondary Phone (Work/Home)Client's children if adult / siblings if childNameSexDate of BirthLiving at Home? Add RemoveDoes client work?* No Yes Name of EmployerOccupationList all allergiesList any Medical Problems Your Therapist should be aware ofCurrent Medications Including OTCName of MedicationDoseFrequency Add RemoveHave you had previous psychiatric hospitalizations?* No Yes Please list the hospitalizations:Hospital NameDate of AdmissionDate of DIscharge Add RemoveHave you had previous outpatient therapy?* No Yes TherapistTherapistDates Add RemoveSpiritual HistoryIn what denomination were you raised?How do you feel about God?In what ministries are you involved?Have you ever been involved willingly or unwillingly in any of the following? Witchcraft WICCA SRA Other cults Academic History Adults complete this too.Highest grade achieved* High School GED Some College 2-Yr College 4-Yr College Masters Doctoral Other Are you currently a student?* No Yes Current GradeName of SchoolDid you have any learning problems?Were you placed in Special Education?Which grade(s) did you repeat?Any problems with separation from parents?Behavior problems?Decline in grades?School refusal / absenteeism?Legal History Please be as complete as you can.Please list all incidents of DUI, DWI, arrests, violence, incarcerations, etc.DescriptionDateWhere this occurred Add RemoveCurrent and Recent Symptoms Please select all that apply to your past. If it is something experienced in THE LAST MONTH select NOW.Anger Now Past Nightmares Now Past Anxiety Now Past Cursing Now Past Sleepless Nights Now Past Bed-wetting Now Past Destroying property Now Past Sleeping too much Now Past Wetting or soiling self (day) Now Past Eating too much / binging Now Past Have no energy Now Past Fears Now Past Verbally abusive Now Past Guilt Now Past Panic Now Past Hurting yourself Now Past Crying Now Past Phobia Now Past Seeking sexual activity Now Past Shame Now Past Clumsiness Now Past Lying Now Past Problem concentrating Now Past Poor sexual performance Now Past Fighting Now Past Weight gain Now Past Decreased sexual desire Now Past Spending too much Now Past Increased appetite Now Past Feeling restless / keyed up Now Past Stealing something Now Past Decreased or no appetite Now Past Difficulty paying attention Now Past Tantruming Now Past Weight loss Now Past Difficulty organizing tasks Now Past Throwing things Now Past Isolating from others Now Past Forgetful of daily activities Now Past Using drugs not prescribed Now Past Lacking motivation Now Past Failure to follow directions Now Past Using illicit drugs Now Past Low self-esteem Now Past Feeling like a child when upset Now Past Using alcohol Now Past Racing thoughts Now Past Flashbacks Now Past Desire to hurt / kill someone Now Past Too much energy Now Past Hypervigilance Now Past Wanting to kill yourself Now Past Feel like running away Now Past Exaggerated startle Now Past Watching pornography Now Past Hearing voices Now Past Seeing things not there Now Past Lack of pleasure in most things Now Past Sad or empty most days Now Past Irritable Now Past Relationships and Relationship Skills Please rate your relationship(s) with each of the following.Mother Good Fair Poor Not applicable Female sibilings Good Fair Poor Not applicable Female friends Good Fair Poor Not applicable Female teachers Good Fair Poor Not applicable Female bosses Good Fair Poor Not applicable Female in authority Good Fair Poor Not applicable Father Good Fair Poor Not applicable Male sibilings Good Fair Poor Not applicable Male friends Good Fair Poor Not applicable Male teachers Good Fair Poor Not applicable Male bosses Good Fair Poor Not applicable Male in authority Good Fair Poor Not applicable Listening skills Good Fair Poor Not applicable Ability to express my thoughts and feelings Good Fair Poor Not applicable Substance Use History Do you have a history of substance use?* No Yes At what age did you start?Date of last useWhat influenced you to start?Drugs of choiceWhat treatment(s) have you received for substance use? None NA or AA Detox Rehab Individual therapy Group therapy Intensive outpatient Other History Check and elaborate on all that apply.Emotional or verbal abuse Yes Physical abuse Yes Sexual abuse Yes Neglect Yes Parents or Self Divorced Yes Involved in any accidents Yes Death of a loved one or pet Yes Abortion Yes Multiple moves Yes Immigrated (from where, at what age) Yes What brings you to counseling at this time?Signature Client or Legal Guardian signature.Who is signing?* Client Parent/Guardian/Legal Authority Print the Name of Person Signing the Form:*Date Signed* MM slash DD slash YYYY I acknowledge that I am 18 years old or have legal authority to sign for the Client* Yes EmailThis field is for validation purposes and should be left unchanged.
