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Ephesians Professional Counseling

Ephesians Professional Counseling

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Ephesians Professional Counseling

CLIENT ASSESSMENT

Client Information

Please fill in this section with the Client's information.

Name*
Birthday*
MM slash DD slash YYYY
Address*
If Client is a Minor, Parents' or Legal Representative's Name(s):
Client is:*

Emergency Contact Information

In case of an emergency please provide a person we can contact.

Client's children if adult / siblings if child
Name
Sex
Date of Birth
Living at Home?
 
Does client work?*
Current Medications Including OTC
Name of Medication
Dose
Frequency
 
Have you had previous psychiatric hospitalizations?*
Please list the hospitalizations:
Hospital Name
Date of Admission
Date of DIscharge
 
Have you had previous outpatient therapy?*
Therapist
Therapist
Dates
 

Spiritual History

Have you ever been involved willingly or unwillingly in any of the following?

Academic History

Adults complete this too.

Highest grade achieved*

Are you currently a student?*

Legal History

Please be as complete as you can.

Please list all incidents of DUI, DWI, arrests, violence, incarcerations, etc.
Description
Date
Where this occurred
 

Current and Recent Symptoms

Please select all that apply to your past. If it is something experienced in THE LAST MONTH select NOW.

Anger
Nightmares
Anxiety
Cursing
Sleepless Nights
Bed-wetting
Destroying property
Sleeping too much
Wetting or soiling self (day)
Eating too much / binging
Have no energy
Fears
Verbally abusive
Guilt
Panic
Hurting yourself
Crying
Phobia
Seeking sexual activity
Shame
Clumsiness
Lying
Problem concentrating
Poor sexual performance
Fighting
Weight gain
Decreased sexual desire
Spending too much
Increased appetite
Feeling restless / keyed up
Stealing something
Decreased or no appetite
Difficulty paying attention
Tantruming
Weight loss
Difficulty organizing tasks
Throwing things
Isolating from others
Forgetful of daily activities
Using drugs not prescribed
Lacking motivation
Failure to follow directions
Using illicit drugs
Low self-esteem
Feeling like a child when upset
Using alcohol
Racing thoughts
Flashbacks
Desire to hurt / kill someone
Too much energy
Hypervigilance
Wanting to kill yourself
Feel like running away
Exaggerated startle
Watching pornography
Hearing voices
Seeing things not there
Lack of pleasure in most things
Sad or empty most days
Irritable

Relationships and Relationship Skills

Please rate your relationship(s) with each of the following.

Mother
Female sibilings
Female friends
Female teachers
Female bosses
Female in authority
Father
Male sibilings
Male friends
Male teachers
Male bosses
Male in authority
Listening skills
Ability to express my thoughts and feelings

Substance Use History

Do you have a history of substance use?*
What treatment(s) have you received for substance use?

History

Check and elaborate on all that apply.

Emotional or verbal abuse
Physical abuse
Sexual abuse
Neglect
Parents or Self Divorced
Involved in any accidents
Death of a loved one or pet
Abortion
Multiple moves
Immigrated (from where, at what age)

Signature

Client or Legal Guardian signature.

Who is signing?*
MM slash DD slash YYYY
I acknowledge that I am 18 years old or have legal authority to sign for the Client*
This field is for validation purposes and should be left unchanged.
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Contact:
ephesians@ephesians.org
301-439-7191
Contact:
ephesians@ephesians.org
301-439-7191
Locations:
College Park Bethesda
4920 Niagara Road 5910 Goldsboro Road
Suite 308 Bethesda, MD 20817
College Park, MD 20740 301-466-2050
301-439-7191
» Handicapped Accessible
Location:
College ParkBethesda
4920 Niagara Road--Teletherapy Only
Suite 308 301-466-2050
College Park, MD 20740
301-439-7191
ยป Handicapped Accessible
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