Name:_______________________________ DOB:_________________ Age:____________________________ Phone: Mobile:(____)__________________ Home:(____)____________________________________________ Address:_____________________________________________________________________________________ Email address:________________________________________________________________________________ Referred by:__________________________ Primary Physician:________________________________________ Emergency Contact:____________________ Relation: ______________Phone:(_____)_____________________ Member of St. Andrew United Methodist Church? ( ) Yes ( ) No.
In a few words, what are the issues/problems you are seeking help for today?
Current Symptoms/Problem Checklist: Please check any symptoms…

( ) Depression
( ) Excessive worry ( ) Substance Abuse ( ) Increase risky behavior ( ) Avoidance ( ) Increased/decreased libido ( ) Hallucinations ( ) Loss/Bereavement ( ) Decrease need for sleep ( ) Suspiciousness ( ) Pain Issues

Suicide Risk
Have you ever tried to harm yourself in the past? ( ) Yes ( ) No.
Have you had any recent thoughts, or do you currently have any thoughts of suicide? ( )Yes ( )No.

Medical History:
List ALL current medications
and how often you take them/dosage:
Current over-the-counter medications or supplements:________________________________________________ Current/Past major medical problems (chronic illness, surgeries, hospitalizations…) ____________________________________________________________________________________________ Family History (Medical/Psychiatric Diagnoses, Substance Abuse or Self-Injury/Suicide): ____________________________________________________________________________________________ ____________________________________________________________________________________________ Past Psychiatric History:
Outpatient treatment ( ) Yes ( ) No. If yes, Please describe when, by whom, and nature of treatment.
____________________________________________________________________________________________ Psychiatric Hospitalization ( ) Yes ( ) No. If yes, describe for what reason, when and where. ____________________________________________________________________________________________ ____________________________________________________________________________________________
Past Psychiatric Medications:
If you have ever taken any of the following medications:
(please circle).
Prozac, Zoloft, Luvox, Paxil, Celexa, Lexapro, Viibryd, Effexor, Cymbalta,Wellbutrin, Remeron, Serzone,
Anafranil, Pamelor,Tofranil, Elavil, Tegretol, Lithium, Lamictal, Tegretol, Topamax, Seroquel, Zyprexa, Geodon, Abilify,
Clozaril, Haldol, Prolixin
Anxiety: Xanax, Ativan, Klonopin, Valium, Restoril, Librium,Tranxene, Buspar, Vistaril, Benadryl, Propranolol
Sleep: Ambien, Lunesta, Sonata, Rozerem, Restoril, Desyrel/trazodone
ADHD: Adderall, Concerta, Ritalin, Vyvanse, Focalin, Dexedrine, Strattera
Other: ______________________________________________________________________________________
Any positive/negative experiences with these medications? ___________________________________________

Substance Use:
Do you (or others) think you may have a problem with alcohol or drug use? ( ) Yes ( ) No
Have you ever been treated for alcohol or drug use or abuse? ( ) Yes ( ) No
If yes, for which substances and when/where were you treated?
Days/wk drinking alcohol: __________ Avg. Number drinks/day: __________ Most drinks/day: _____________
Do you have current/past problems with the use/abuse of illegal substances? If so, which substances?
Have you abused prescription medication? If so, which medications?
How many caffeinated beverages do you drink a day? Coffee ___________ Sodas ________ Tea ____________
Tobacco History: active__________________________ past_______________________________________
Family Background and Childhood History:
Where were you born___________________________ where did you grow up ____________________________
Were you adopted? ( ) Yes ( ) No
Did your parents’ divorce? ( ) Yes ( ) No Your age at their divorce:_______ you lived with___________________
List your siblings and their ages: Sisters (ages)______________________________________________________
Brothers (ages)________________________________________________________________________________
Educational History:
What is your highest educational level or degree attained?
Spiritual life: Do you belong to a particular religion or spiritual group?

Trauma History:
Do you have a history of being abused emotionally, sexually, physically or by neglect? ( ) Yes ( ) No.

Occupational History:
Are you currently: ( ) Working ( ) Not working by choice ( ) Unemployed ( ) Disabled ( ) Retired
What is/was your occupation? ___________________________________________________________________
Have you ever served in the military? _______ If so, what branch and when? ______________________________
Relationship History and Current Family:
Are you currently: ( ) Married ( ) Divorced ( ) Single ( ) Widowed
How long? _____ Total number of marriages?______
If not married, are you currently in a relationship? ( ) Yes ( ) No If yes, how long? __________________________
Do you have children? ( ) Yes ( ) No. If yes, list ages and gender________________________________________
Legal: Do you have any pending legal problems?____________________________________________________
Other Information:___________________________________________________________________________

Source: http://hhiumc.squarespace.com/storage/pdf-files/Counseling%20-%20New%20Client%20Intake%20History.pdf


Sicherheits-Info für „Neulinge“ Wer zum ersten Mal auf eine Hochseeyacht eingeladen wird, fragt meist: "Was muss ich mitnehmen, was muss ich beachten?" Diese Liste sol neuen Mitseglern helfen. Jeder weiss, dass die See gefährlich ist und die wichtigste Aufgabe des Skippers darin besteht, alle Mitsegler vor Schaden zu bewahren. Deshalb geht es nicht ohne Sicherheitseinweis

Microsoft word - sanp i v therapy policy - 2013

Saskatchewan Association of Naturopathic Practitioners For the purpose of this policy, Intravenous (I.V.) Therapy refers to the use of injectable nutrients administered intravenously to supplement and support health. REQUIREMENTS FOR THE PRACTICE OF I.V. THERAPY IN SASKATCEHEWAN Registrants wishing to practice I.V. Therapy must comply with the following requirements: - Successful completion of

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