Microsoft word - grace pif mod.docx

Name______________________________________________ PRESENTING PROBLEMS-Why are you coming to counseling?

Main problems
Duration (months)
Additional information:
Visual Auditory Kinetic Concrete Sequential Global Abstract Random Analytical CURRENT SYMPTOM CHECKLIST (Rate intensity of symptoms currently present)
None = This symptom not present at this time • Mild = Impacts quality of life, but no significant impairment of day-to-day functioning
Moderate = Significant impact on quality of life and/or day-to-day functioning • Severe = Profound impact on quality of life and/or day-to-day functioning
SPIRITUAL HISTORY
Current Church attending: ___________________________________________ Church attendance per month (circle) 0 1 2 3 4 5 6 7 8 9 10 10+ Denominational preference: __________________________________ Membership: _____________________________ Church attended in childhood: _______________________ Baptized? Yes _____ No _____ When? ________________ Do you pray to God? Never____ Occasionally ____ Often ____ How frequently do you read the Bible?
Do you have regular personal devotions? Yes ____ No ____ Do you have regular family devotions? Yes ____ No ____
Explain any recent changes in your religious life:__________________________________________________________
Are you saved? Yes _____ No _____ Not sure what you mean _____
Describe your personal understanding of how someone has a relationship with God ___________________________________________________________
______________________________________________________________________________________________________________________________
Describe how to be controlled by the Holy Spirit ______________________________________________________________________________________
______________________________________________________________________________________________________________________________
Would you describe yourself as a growing___ struggling___ stagnant___ young___ mature___ disillusioned___ Christian? Other?_____________________
Summarize what you believe is your relationship with God.______________________________________________________________________________
______________________________________________________________________________________________________________________________
EMOTIONAL/ PSYCHIATRIC HISTORY
[ ] [ ] Prior outpatient psychotherapy?
No Yes If yes, on
[ ] [ ] Has any family member had outpatient psychotherapy? If yes, who/why (list all):
[ ] [ ] Prior inpatient treatment for a psychiatric, emotional, or substance use disorder?
No Yes If yes, on
[ ] [ ] Has any family member had inpatient treatment for a psychiatric, emotional, or substance use disorder? If yes,
No Yes who/why (list all):
Personal Prior or Current Psychotropic Medication Usage? If yes:
___________
______ _________ ________ _______ ________________ ____________ ___________________

[ ] [ ] Has any family member used psychotropic medications? If yes, who/what/why (list all):
FAMILY HISTORY
FAMILY OF ORIGIN
Present during childhood:
Parents' current marital status:
Describe parents:
Describe childhood family experience:
[ ] witnessed physical/verbal/sexual abuse toward others [ ] experienced physical/verbal/sexual abuse from others Age of emancipation from home:
Circumstances:
Special circumstances in childhood:
IMMEDIATE FAMILY
Marital status:
Intimate relationship:
List all persons currently living in patient's household:
[ ] never been in a serious relationship Relationship satisfaction:
List children not living in same household as patient:
[ ] somewhat satisfied with relationship Describe any past or current significant issues in intimate relationships:
Describe any past or current significant issues in other immediate family relationships:
MEDICAL HISTORY (check all that apply for the client)
Describe current physical health: [ ] Good [ ] Fair [ ] Poor
Is there a history of any of the following in the family:
List name of primary care physician:
List name of psychiatrist: (if any):
What is the date of your last physical? _________________________

List any medications currently being taken (give dosage & reason):
[ ] other chronic or serious health problems Describe any serious hospitalization or accidents:_____________________________________________________________________________

List any known allergies:
List any abnormal lab test results:
Date

SUBSTANCE USE HISTORY (check all that apply for the client)
Family alcohol/drug abuse history:
Substances used:
Current Use
(complete all that apply)
First use age
Last use age (Yes/No) Frequency Amount
[ ] grandparent(s) [ ] spouse/significant other Substance use status:
Treatment history:
[ ] outpatient (age[s]______________) Consequences of substance abuse (check all that apply):
[ ] inpatient (age[s]
[ ] loss of control amount used [ ] relationship conflicts [ ] other (describe) _________________________________________________________________________________________________ DEVELOPMENTAL HISTORY (check all that apply for the client)
Problems during
Childhood health:
mother's pregnancy:
Infancy:

Delayed developmental milestones (check only
Emotional / behavior problems (check all that apply):
those milestones that did not occur at expected age): [ ] disobedient [ ] lack of attachment _________________
Social interaction-check all that apply (See next page also)
Intellectual / academic functioning-check all that apply (See next page also)
[ ] normal social interaction [ ] inappropriate sex play
Describe any other developmental problems or issues:
GENERAL HISTORY (check all that apply for the client) Living situation:
Social support system:
Sexual history:
[ ] currently sexually satisfied [ ] history of unsafe sex age to Military history:
Cultural/spiritual/recreational history:
Employment:
cultural identity (e.g., ethnicity, religion): [ ] served in military - with incident describe any cultural issues that contribute to current problem:
currently active in community/recreational activities? Yes [ ] No [ ] Legal history:
formerly active in community/recreational activities? Yes [ ] No [ ] currently participate in spiritual activities? if answered "yes" to any of above, describe: Financial situation:
_________________________________________________________ Educational History:
Highest grade:_____________________________________________ Major in College:__________________________________________ describe last legal difficulty: ____ Currently in education with what goal:_________________________ [ ] relationship conflicts over finances _______________________________________________________
PERSONALITY INFORMATION Circle the following words that best describe you now. Please pick ONE PER LINE from each column.
YOU SHOULD HAVE 10 CIRCLES WHEN YOU ARE DONE.
PROJECTS ARE EXPECTED TO BE COMPLETED. PAYMENT IS TO BE MADE AT THE TIME OF THE APPOINTMENT. CANCELLATIONS MADE WITHIN 24 HOURS REQUIRE HALF PAYMENT FOR THE APPOINTMENT. ___________________________________________ _____________________________ Signature

Source: http://www.gracecounselingkc.com/wp-content/uploads/2011/06/Grace-PIF.pdf