CHERYL DESMIDT, LMFT

New Client Background

To allow us to best serve you, please complete this form with as much accuracy and honesty as possible.

Last Name: First:

DOB: Age: Cell: Email:

YOUR PERSONAL HISTORY

Place of birth:

Please list previous places you have lived:

Height: Weight: Last Physical Exam:

Primary Care Physician: Phone

Psychiatrist: Phone

Marital Status: Married Divorced Widowed Separated Single Living with Partner

Number of times married: Number of children:

Names and ages of children:

Where are children living now?

Please describe your feelings regarding your current situation:

YOUR FAMILY HISTORY

Please list significant family members (parents, siblings and others), living and deceased, their relationship to you and their approximate ages.

(Note IF applicable: SA= substance abuse, MI = mental illness, VS = violence to self, VO = violence to others)

Name	Relationship	Age
SA MI VS VO

SA MI VS VO

SA MI VS VO

SA MI VS VO

SA MI VS VO

With whom do you currently reside?

2

Please give the names of family members, including you, who are presently, or in the past have been, under the care of a mental health professional and/or in a substance abuse program:

Name	Issue	Seen when and where

Have you ever deliberately hurt yourself?	No Yes

Have you ever attempted suicide?	No Yes

Have you ever assaulted another person?	No Yes

Do you have a history of fire setting?	No Yes

Do you have a history of animal cruelty?	No Yes

CURRENT PHYSICAL HEALTH

Current Health Issues	By whom are you being treated?

Any known allergies:

Current medications:

Are you compliant with your prescribed medications? Yes No N/A

Previous significant health problems (illnesses and surgeries):

Previous hospitalizations (medical and psychiatric):

SUBSTANCE USE INFORMATION

Do you drink regular coffee?	No Yes	How many cups per day?

Do you smoke cigarettes?	No Yes	How many per day?

Do you drink alcohol?	No Yes	How much per week?

Do you use other drugs?	No Yes	Name(s)

Date of last use (drugs or alcohol)

3

SCHOOL / EDUCATION / RELIGIOUS HISTORY

Please describe your educational history: Highest grade completed, certificates, training:

Military Service: No Yes Branch:

Discharge Type: Honorable Dishonorable Medical

Current Occupation:

Current Employer:

Please list the types of jobs you have held in the past:

Please list religious affiliations and/or name(s) of place(s) of worship:

List any religious or cultural beliefs that may interfere with your treatment:

PEER INTERACTION AND SELF PERCEPTION

In the past few years have you had difficulty getting along with others?

What feedback do you get about yourself from others?

How do you generally handle your anger?

Has your anger ever gotten you into trouble? If so, how?

What do you consider your character strengths?

What do you consider your character weaknesses?

Do you have a best friend?

How do you unwind / relax?

Do you have a hobby?

What do you do for fun?

4

PROBLEM AREAS

Circle the areas in which you are experiencing difficulties at this time:

Acute Pain

Alcohol Use

Ambition

Anger

Anxiety

Appearance

Appetite

Bowel troubles

Career choice

Chronic pain

Concentration

Decision making

Depression

Distressing thoughts

Drug use

Eating habits

Elevated mood

Energy level

Family

Fears

Finances

Friends

Gambling

Habits

Health

Hearing voices

History of abuse

Impulsive behavior

Inferiority

Legal issues

Loneliness

Love / Affection

Marital issues

Memory

Mood swings

Motivation

Nervousness

Nightmares

Occupational issues

Panic

Paranoia

Parenting

Racing thoughts

Relationships

Relaxation

Repeating thoughts

Resentment

Revengeful thoughts

Seeing things

Self-control

Self-mutilation

Separation

Sexual issues

Shyness

Sleep

Stomach trouble

Stress

Study habits

Suicidal thoughts

Tiredness

Unhappiness

Weight

Other:

PRESENTING PROBLEM

If there is one, please describe the specific issue that has brought you to our office:

Describe your current feelings about the issue:

What steps have you already taken to correct the issue?

Please give any other information that you feel is relevant:

How do you want us to help you?

5

If your family is aware, what is their attitude toward your issue?

If applicable, describe benefits obtained through previous treatment:

LEVELS OF COPING SKILLS

On a Scale of 1 – 10, With 10 Being the Best,

What Is Your Current Level of Coping?

What Is Your Highest Level of Coping in the Past Year?

Signature	Date