Personal Background Form: Mental Health Assessment | Summaries Religion

PERSONAL BACKGROUND FORM

Please fill out this form as honestly and accurately as possible. You have a right to choose not to

disclose any information requested in this form and can instead choose to discuss it privately

with your therapist/assessor. Please note that your therapist/assessor and staff will see your

responses to these questions and this information will become an official part of your medical

record. Your information is confidential and will not be disclosed to third parties without your

consent. This information will be used to help meet your healthcare needs as well as to allow us

to identify any potential gaps in care in our clinic. We strive to provide the best healthcare

possible, and we appreciate your assistance in this process.

Full Legal Name: ________________________________________________

1. Select one:



Single



Married



Divorced



Widowed



Living with intimate partner



Dating

2. What is your current living situation?:



Roommate



Significant other/romantic partner



Parents



Siblings



Other (please specify: ________________________________________________)

CULTURAL BACKGROUND

3. Please describe your ethnic/racial identity in your own words:

_________________________________________________________________________________________________________

4. Please describe your gender identity and preferred pronoun in your own words:

_________________________________________________________________________________________________________

5. Please describe your sexual orientation in your own words:

_________________________________________________________________________________________________________

6. What is your religious or spiritual affiliation if any?

_________________________________________________________________________________________________________

7. Do you have any cultural backgrounds that are important to you (e.g., nationality,

religion, spirituality, education, economic status, race/ethnicity, gender identity, sexual

orientation)? If yes, please give a brief description:

_________________________________________________________________________________________________________

EMPLOYMENT

8. Are you currently employed?  Yes, full-time  Yes, part-time  No, currently unemployed

If yes, what type of work do you do? ________________________________________________________

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Download Personal Background Form: Mental Health Assessment and more Summaries Religion in PDF only on Docsity!

PERSONAL BACKGROUND FORM

Please fill out this form as honestly and accurately as possible. You have a right to choose not to

disclose any information requested in this form and can instead choose to discuss it privately

with your therapist/assessor. Please note that your therapist/assessor and staff will see your

responses to these questions and this information will become an official part of your medical

record. Your information is confidential and will not be disclosed to third parties without your

consent. This information will be used to help meet your healthcare needs as well as to allow us

to identify any potential gaps in care in our clinic. We strive to provide the best healthcare

possible, and we appreciate your assistance in this process.

Full Legal Name: ________________________________________________

1. Select one:

 Single  Married  Divorced  Widowed  Living with intimate partner  Dating

2. What is your current living situation?:

 Roommate  Significant other/romantic partner  Parents  Siblings  Other (please specify: ________________________________________________)

CULTURAL BACKGROUND

3. Please describe your ethnic/racial identity in your own words:

_________________________________________________________________________________________________________

4. Please describe your gender identity and preferred pronoun in your own words:

_________________________________________________________________________________________________________

5. Please describe your sexual orientation in your own words:

_________________________________________________________________________________________________________

6. What is your religious or spiritual affiliation if any?

_________________________________________________________________________________________________________

7. Do you have any cultural backgrounds that are important to you (e.g., nationality,

religion, spirituality, education, economic status, race/ethnicity, gender identity, sexual

orientation)? If yes, please give a brief description:

_________________________________________________________________________________________________________

EMPLOYMENT

8. Are you currently employed?  Yes, full-time  Yes, part-time  No, currently unemployed

If yes, what type of work do you do? ________________________________________________________

9. Please estimate your income before taxes (not including spouse’s income) in any of the

following ways:

i. Hourly ____________________________

ii. Weekly ____________________________

iii. Monthly ___________________________

iv. Yearly _____________________________

10. Please indicate the number of adults & children living in your household:

adults children

11. How satisfied are you with your currently financial situation?

 Not Satisfied at all  Somewhat Satisfied  Very Satisfied

EDUCATION

12. How many years of schooling have you completed? _________________________

13. Are you currently in school?

 Yes  No

If yes, what are you studying?

_____________________________________________________________________________

14. Have you experienced any academic or personal difficulties in school?

_________________________________________________________________________________________________________

15. How well did you do in school? (e.g., grades, teacher’s report, subjects of

strengths/weaknesses)

_________________________________________________________________________________________________________

16. Have you ever been diagnosed with a learning disability?

 Yes  No

Have you been assessed for this disability in the past? If so, when?

_____________________________________________________________________________

FAMILY INFORMATION

17. Spouse/Partner: _________ _

Name Age Living w You?

SOCIAL RELATIONSHIPS

21. How would you describe your social support network (e.g., parents, siblings, friends,

romantic partners)?

_________________________________________________________________________________________________________

22. How satisfied are you with your currently social relationships?

 Not Satisfied at all  Somewhat Satisfied  Very Satisfied

MEDICAL HISTORY

23. Have you had a physical examination within the last six months?  Yes  No

If yes, what were the results:

_____________________________________________________________________

24. Are you currently receiving medical care?  Yes  No

If yes, please describe briefly:

_______________________________________________________________________________

_____________________________________________________________________________________________________

25. Name of physician in case of emergency: ______________ Phone: _

26. Have you experienced any of the following health problems? Please check all that apply:

 High blood pressure/Hypertension  Ulcer or gastrointestinal problem  Cardiac/Heart problems  Kidney disorder  Cancer  Chronic or frequent headaches  Diabetes  Dizziness  Respiratory problems  Fainting or Blackouts  Chronic pain  Injury: What kind? _________________  Stroke  Seizures/Convulsions  Headaches  Memory problems  Thyroid Issues  Asthma  Any other health problems? ___________________________________________________________________

27. Have you been hospitalized for illness or injury in the past 10 years?  Yes  No

If yes, approximate dates and condition: __________________________________________________

28. Have you been hospitalized for a psychiatric/psychological reason?  Yes  No

If yes, approximate dates and issue: _________________________________________________________

29. Are you currently taking any medications?  Yes  No

Type of Medication Average Dosage Frequency

_______________________________ _

30. Have there been any serious illnesses, accidents, deaths or other physical concerns

within your family in the past 5 years?  Yes  No

If yes, please specify:

_________________________________________________________________________________________________

__________________________________________________________________________________________________

PREVIOUS SERVICES

31. Have you ever had any personal (individual) psychotherapy?  Yes  No

If yes, for what concern? _____________________________________________________________________________

Approximate date: ___________________________ For how long? _______________________________________

32. Have you ever had couple counseling or family therapy?  Yes  No

If yes, for what concern? ____________________________________________________________________________

Approximate date: _________________________ For how long? ________________________________________

33. If you have received therapy before, was it helpful?  Yes  No

If yes, in what way was it helpful?

If not, in what way was it unsatisfactory?

SUBSTANCE USE

34. Have you ever used any drugs or medications other than as prescribed (for

recreational purposes)? This includes prescription medications, marijuana, PCP, LSD,

amphetamines, barbiturates, cocaine, opiates, ecstasy, and others.

 Yes  No

Are you currently using any of these drugs?  Yes  No

If you have used any drugs or medications other than prescribed, please fill out the requested information: Type Frequency/Amount (How much?) Duration (How long?) How taken (Injected? Orally?)

Personal Background Form: Mental Health Assessment, Summaries of Religion

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Partial preview of the text

Download Personal Background Form: Mental Health Assessment and more Summaries Religion in PDF only on Docsity!

PERSONAL BACKGROUND FORM

Please fill out this form as honestly and accurately as possible. You have a right to choose not to

disclose any information requested in this form and can instead choose to discuss it privately

with your therapist/assessor. Please note that your therapist/assessor and staff will see your

responses to these questions and this information will become an official part of your medical

record. Your information is confidential and will not be disclosed to third parties without your

consent. This information will be used to help meet your healthcare needs as well as to allow us

to identify any potential gaps in care in our clinic. We strive to provide the best healthcare

possible, and we appreciate your assistance in this process.

Full Legal Name: ________________________________________________

1. Select one:

2. What is your current living situation?:

CULTURAL BACKGROUND

3. Please describe your ethnic/racial identity in your own words:

_________________________________________________________________________________________________________

4. Please describe your gender identity and preferred pronoun in your own words:

_________________________________________________________________________________________________________

5. Please describe your sexual orientation in your own words:

_________________________________________________________________________________________________________

6. What is your religious or spiritual affiliation if any?

_________________________________________________________________________________________________________

7. Do you have any cultural backgrounds that are important to you (e.g., nationality,

religion, spirituality, education, economic status, race/ethnicity, gender identity, sexual

orientation)? If yes, please give a brief description:

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

EMPLOYMENT

8. Are you currently employed?  Yes, full-time  Yes, part-time  No, currently unemployed

If yes, what type of work do you do? ________________________________________________________

9. Please estimate your income before taxes (not including spouse’s income) in any of the

following ways:

i. Hourly ____________________________

ii. Weekly ____________________________

iii. Monthly ___________________________

iv. Yearly _____________________________

10. Please indicate the number of adults & children living in your household:

______ adults ______ children

11. How satisfied are you with your currently financial situation?

EDUCATION

12. How many years of schooling have you completed? _________________________

13. Are you currently in school?

If yes, what are you studying?

_____________________________________________________________________________

14. Have you experienced any academic or personal difficulties in school?

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

15. How well did you do in school? (e.g., grades, teacher’s report, subjects of

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

16. Have you ever been diagnosed with a learning disability?

Have you been assessed for this disability in the past? If so, when?

_____________________________________________________________________________

FAMILY INFORMATION

17. Spouse/Partner: _____________________________ ______ ___________________

SOCIAL RELATIONSHIPS

21. How would you describe your social support network (e.g., parents, siblings, friends,

romantic partners)?

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

22. How satisfied are you with your currently social relationships?

MEDICAL HISTORY

23. Have you had a physical examination within the last six months?  Yes  No

If yes, what were the results:

_____________________________________________________________________

24. Are you currently receiving medical care?  Yes  No

If yes, please describe briefly:

_______________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

25. Name of physician in case of emergency: ____________________________ Phone: _______________

26. Have you experienced any of the following health problems? Please check all that apply:

27. Have you been hospitalized for illness or injury in the past 10 years?  Yes  No

adults children

17. Spouse/Partner: _________ _

25. Name of physician in case of emergency: ______________ Phone: _

_______________________________ _

_______________________________ _