RICHARD COSTA, LCSW Today's date: ___________________ Client Name: ____________________________________ Birth Date: _______ Age: ____ Address: __________________________________________________________________ City: ___________________________________ State: ____________ Zip:____________ Home phone: _________________________ Work phone: ________________________ INSURANCE INFORMATION Name of Insured: ____________________________________ SSA # _________________ Insurance Company : ________________________________ Group # ________________ Insurance Address: ______________________________________ Phone: ____________ Your doctor: _____________________________________________ Phone: ___________ Your Email Address: ________________________________________________________ CURRENT PROBLEM What brings you to therapy? Be as complete as possible within these lines: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Why have you decided to come in at this time? Be specific about what has happened that makes you come in now. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ What would you like to change about yourself to make your situation better? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ FAMILY INFORMATION ( ) SINGLE ( ) MARRIED ( ) WIDOWED ( ) DIVORCED ( ) SEPARATED Name of spouse/significant other: _________________________________ Age ______ Do you have any children: ______ Name of child: Age Custody When child is with you ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Name of others living with you and relationship to you: Name ________________________________________ Relationship __________________ Name ________________________________________ Relationship __________________ EMPLOYMENT INFORMATION Last grade completed __________ Usual occupation _____________________________________ How long? ___________ Employer _____________________________________________ How long? ___________ Have you ever been unable to work? _______ How long? ______ When? _______ Have you had periods of unemployment? ______ How long? _____ When? _______ How many jobs in the past five years? ________________________________ CHILDHOOD AND FAMILY HISTORY What is your ethnic, cultural, and religious background? ______________________ _________________________________________________________________________ List your brothers and sisters from oldest to youngest and their ages: Name: ____________________ Age ___ Name: _____________________ Age: ______ Name: ____________________ Age ____ Name: _____________________ Age: ______ Name: ____________________ Age ____ Name: _____________________ Age: ______ Did your parents live together throughout your childhood? _____________________ If not, what happened and how old were you? ________________________________ ____________________________________________________________________________ Number of times moved and at what age? ____________________________________ Grew up in ( ) the city ( ) the suburbs ( ) the country Special problems in the family: ( ) disabled child ( ) serious medical illness ( ) death in family ( ) hospitalizations ( ) alcohol and/or drugs ( ) parents fought ( ) parent unemployed ( ) parent changed jobs a lot ( ) legal problems ( ) other _________________________________________________ What were you like as a child? ( ) Had problems learning in school? ( ) Got into trouble in school? ( ) Had problems with the law? Did you have any of these problems with your family? ( ) felt like you did not belong ( ) fought with parents ( ) isolated yourself from family ( ) physically abused ( ) sexually abused ( ) emotionally abused ( ) had too much responsibility ( ) other______________________________________ Take these few lines to describe your childhood and your relationship with your parents. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Do you have any medical problems? ______________ If so, when did each problem start? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Medications Dosage When Medications Dosage When taking taken now taking taken _______________ ________ ______ _____________ _________ ______ _______________ ________ ______ _____________ _________ ______ _______________ ________ ______ _____________ _________ ______ _______________ ________ ______ _____________ _________ ______ What psychiatric medications have you taken in the past? ____________________ ____________________________________________________________________________ PSYCHOLOGICAL HISTORY Previous Counselor From - To Reason(s) ended treatment _________________________ ___________ ______________________________ _________________________ ___________ ______________________________ Have you been hospitalized for psychiatric reasons? Where? When? Where? When? _______________________________________________________________________ Non-prescribed substances you use(d), including alcohol, caffeine, tobacco, amphetamines, cocaine, marijuana, heroin, or others: Substance Current amount & frequency Past amount & frequency _________________ ____________________________ __________________________ CURRENT SYMPTOM CHECK LIST These symptoms may or may not be related to the problem which brings you in to see us. However, they help us plan your treatment. A. ( ) trouble going to sleep ( ) vomiting ( ) restless sleep ( ) hot or cold spells ( ) waking up early and being ( ) numbness or tingling in parts of your unable to go back to sleep body ( ) sleeping too much ( ) allergy problems ( ) feeling guilty ( ) high blood pressure ( ) depressive feelings that are ( ) menstrual irregularity or regularly worse in morning distress ( ) thoughts of suicide ( ) asthma attacks ( ) having made suicide attempts ( ) hives ( ) fatigue or loss of energy ( ) irritable bowels, constipation, ( ) poor concentration and memory diarrhea ( ) decreased sex drive ( ) tics ( ) significant feelings of ( ) smoking restlessness ( ) consumption of products high in ( ) loss of pleasure in usual sugar content/sugar cravings activities ( ) eating disturbance ( ) appetite loss ( ) frequent flu or colds ( ) feeling worthless ( ) minor accidents ( ) weight loss ( ) sinus problems ( ) weight gain ( ) grinding teeth, jaw tension, ( ) feelings of sadness or or pain depression ( ) joint pain ( ) withdrawing from others ( ) metabolic dysfunction (thyroid prob., hypoglycemia, diabetes ( ) heart disease B. ( ) uncontrollable habits ( ) palpitation ( ) other ______________________________ ( ) light headedness ( ) sweating D. ( ) trembling ( ) arguing with others ( ) sense of dread ( ) feeling critical of others ( ) muscle tension ( ) feeling people dislike you ( ) chest pains ( ) feeling shy or uneasy ( ) frequent urination ( ) wanting to be alone often ( ) dizziness ( ) difficulty communicating what ( ) panic attacks really think or feel ( ) shortness of breath ( ) feeling bored with others ( ) cold, clammy hands ( ) feeling inadequate, less than ( ) afraid of losing control others ( ) avoiding certain situations ( ) others do not understand you ( ) feeling lonely even when with others C. ( ) others are inferior to you ( ) nausea, upset stomach, ulcers ( ) others not meeting your needs ( ) headaches ( ) other relationship problems ( ) itching ( ) overeating