BH Adult History

Northwest Behavioral Health

Adult History Form

Please complete as much of this form as you can before your first session. This information will help your counselor understand you better.

Patient Name

First Name

Last Name

Date of Birth

Name of person completing the form (if different from the patient):

Relationship to Patient

Emergency Contact

First Name

Last Name

Phone

Relationship to Patient

Do you have a guardian or payee?

Yes No

Guardian or Payee Name

First Name

Last Name

Relationship to Patient

Phone

If you are working outside the home (in a paying job or as a volunteer), describe the job and how long you have held it:

Please tell us if you are working.

Employed Unemployed Retired Disabled Full-time parent Volunteer

Other:

Check all that apply

Ethnicity, Culture and Religion

Please share any ethnic, cultural or religious concerns that may be helpful to your therapist:

Is English your preferred language? If no, list language:

Yes No

Other:

Would you like an interpreter or other support involved in your therapy?

Present Concerns

Describe the problem or event that brought you here today?

What would you like for your counselor /provider/staff to do for you?

What has led you to seek help at this time?

Have you already tried to resolve these concerns? If so, what did you do and how did it work?

Who do you go to for support (family, friends, faith or spirituality, support or self-help groups)?

What strengths or resources do you have that will help you succeed in counseling? (Examples: commitment, strong family support, intelligence, good social support, church, friends, etc.)

What might prevent your success in counseling? (Examples include: few friends, financial stress, lack of social support, lack of family support, etc?)

What are some of your hobbies or interest?

Military Service

Have you been or are you currently in the military?

Yes No

Branch

Date of Discharge

Type of Discharge

Rank

Were you in combat?

Yes No

Personal History

Tell us about your childhood:

Where did you grow up?

Were your parents married?

Yes No

If divorced, how old were you at the time?

How many siblings do you have?

What is your birth order?

How would you describe your childhood?

Household

Tell us about your current family. Please list the members of your family and household below.

Family Member 1

Name

First Name

Last Name

Age

Relationship

Living in the same house?

Yes No

Would you like to add another family member?*

Yes No

Household

Tell us about your current family. Please list the members of your family and household below.

Family Member 2

Name

First Name

Last Name

Age

Relationship

Living in the same house?

Yes No

Would you like to add another family member?*

Yes No

Household

Tell us about your current family. Please list the members of your family and household below.

Family Member 3

Name

First Name

Last Name

Age

Relationship

Living in the same house?

Yes No

Would you like to add another family member?*

Yes No

Household

Tell us about your current family. Please list the members of your family and household below.

Family Member 4

Name

First Name

Last Name

Age

Relationship

Living in the same house?

Yes No

Would you like to add another family member?*

Yes No

Household

Tell us about your current family. Please list the members of your family and household below.

Family Member 5

Name

First Name

Last Name

Age

Relationship

Living in the same house?

Yes No

Would you like to add another family member?*

Yes No

Household

Tell us about your current family. Please list the members of your family and household below.

Family Member 6

Name

First Name

Last Name

Age

Relationship

Living in the same house?

Yes No

Would you like to add another family member?*

Yes No

Household

Tell us about your current family. Please list the members of your family and household below.

Family Member 7

Name

First Name

Last Name

Age

Relationship

Living in the same house?

Yes No

Would you like to add another family member?*

Yes No

Household

Tell us about your current family. Please list the members of your family and household below.

Family Member 8

Name

First Name

Last Name

Age

Relationship

Living in the same house?

Yes No

Would you like to add another family member?*

Yes No

Household

Tell us about your current family. Please list the members of your family and household below.

Family Member 9

Name

First Name

Last Name

Age

Relationship

Living in the same house?

Yes No

Would you like to add another family member?*

Yes No

Household

Tell us about your current family. Please list the members of your family and household below.

Family Member 10

Name

First Name

Last Name

Age

Relationship

Living in the same house?

Yes No

Would you like to add another family member?*

Yes No

Mental Health and Chemical Dependency in your Family or Origin

Please list any relatives (blood relatives) who have had mental health issues.

Depression:

List blood relatives.

Bipolar/Manic Depression:

List blood relatives.

Anxiety (panic attacks, obsessive-compulsive disorder, phobias):

List blood relatives.

Schizophrenia:

List blood relatives.

Suicide:

List blood relatives.

Eating Disorder:

List blood relatives.

Attention Deficit Disorder:

List blood relatives.

Drug or Alcohol Abuse or Dependency:

List blood relatives.

Ethnicity, Culture and Religion

Mental Health and Chemical History

Present Concerns

Military Service

Personal History

Household

Household

Household

Household

Household

Household

Household

Household

Household

Household

Personal History Continued

Mental Health and Chemical Dependency in your Family or Origin

Your Mental Health and Chemical Dependency History

Substance Use History

Trauma and Abuse History

Safety Concerns

Medical Status