Personal History Questionnaire

Today's Date*
Date of Assessment*
Clinical ID #
Client First Name*
Client Last Name*
Client Email Address
Enter Email Confirm Email
Client Phone Number
Client Date of Birth*
Current Age*
Sex*
- Male
- Female
- Prefer Not To Answer
Name of Person Completing Form*
First Last
Referral Source
Referral Source*
- Community Provider
- County
- Family/Friend
- Law Enforcement
- Medical Facility
- School/College
- Self
Community Provider
County
Family/Friend
Law Enforcement
Medical Facility
School/College
Self
Assessment Overview
Presenting Problem(s)/Reason for Assessment*
When and how did the problem(s) start*
Please select the symptoms you are having now*
(select all that apply)
Other symptoms (please explain)*
How have the problems/symptoms affected your life?*
Areas that have been impaired by the symptoms:*
(select all that apply)
Other areas (please explain):*
What have you already done on your own to help?*
Mental Health History

Please list previous mental health services (include therapy, psychiatry, hospitalizations, commitments, county services, etc):

Date of service:	Where were you seen/treated:	Focus of treatment:

List current and previous medications you have been prescribed for mental health or psychiatric reasons:

Name of medication:	Dosage (if known):	Reason for use (if known):	Current or previous?

Have you ever had thoughts or actions of suicide or self-harm? Or harming another person?*
- Yes
- No
Please explain:*
List your strengths and vulnerabilities:*
Family History
Where were you born and where did you grow up?*
By whom were you raised? What was it like growing up in your family?*
Was there any violence in your family (verbal, emotional, sexual, physical)?*

Please provide the following information about your parents or step-parents:*

Name/Relationship	Age	Occupation	Alive? (yes/no)

Are your parents divorced?*
- Yes
- No
How old were you at the time of the divorce?*

Please complete the following information about your siblings, step-siblings, or half siblings (if applicable):

Name/Relationship	Age	Occupation	Alive? (yes/no)

Please describe your current relationships with your parents and siblings:*
Have any of your family members been treated for or diagnosed with a mental illness?*
- Yes
- No
Please explain.*
Are you aware of any developmental problems or concerns from pre-birth/ childhood/ adolescence?*
- Yes
- No
Please explain.*
Social/Relationship History
Are you currently married or in a relationship?*
- Yes
- No
Please provide partner's name and length of relationship:*
Strengths in relationship?*
Problems in relationship?*
Any previous marriages or significant relationships?*

Please complete the following information about your children or step-children: (if applicable)

Name	Sex	Age	Living with you?	Additional Information

Who is supportive of you or where do you get your support?*
Do you have any spiritual or cultural considerations you would like us to be aware of?*
- Yes
- No
Please explain.*
Do you have a history of maltreatment and/ or abuse?*
- Yes
- No
Please explain.*
What is your sexual orientation? Do you have any concerns with sexuality?*
Education/Work History
Highest level of education:*
Do you have a diploma or GED?*
- No
- GED
- Diploma
What is or was school like for you? Were you ever on Truancy or an Individual Education Plan (IEP)?*
Where are you currently working and how long have you been there?*
Please describe your employment history:*
Have you been in the military?*
- Yes
- No
Medical History
Who is your healthcare provider?
When was your last physical exam?
Describe any current medical problems or physical symptoms you are having:

List any medications you are taking:

Name of medication:	Dosage (if known):	Reason for use (if known):

Please list any important medical information (illnesses, injuries, surgeries, drug side effects):
Do you have any allergies?
- Yes
- No
Please list all known allergies:
Have you ever been hit in the head, or suffered head or brain trauma or injury?
- Yes
- No
Please explain:
Chemical Use History
Have you ever used tobacco?
- Yes
- No
Please describe your tobacco use:
Do you drink alcohol or use drugs?
- Yes
- No
How old were you when you started drinking alcohol or using drugs?
What do you typically use and how much?
Has your use ever concerned you or anyone else?
- Yes
- No
Please explain.
Any negative consequences related to your use?
- Yes
- No
Please explain.
Have you been treated for chemical use?
- Yes
- No
Where did you receive treatment for chemical use?
Do you gamble?
- Yes
- No
Has your gambling ever been a concern and/or caused problems for you?
- Yes
- No
Please explain.
Have you been treated for a gambling addiction?
- Yes
- No
Where did you receive treatment for a gambling addiction?
Please describe your family history of addictions or chemical dependency:
Legal History
Have you ever been convicted of an offense or crime?
- Yes
- No
Please describe the offense or crime.
Are you currently on probation or supervised prison release? Or have you been in the past?
- Yes
- No
Please explain why you were placed on probation or supervised prison release and provide the name of your Probation Officer or Supervising Agent.
Have you been ordered by court/ probation/ parole for assessment, to attend therapy or treatment?
Coordination of Care
Please list any other service providers that are assisting you:
Do you have a Guardian or Conservator?
- Yes
- No

Guardian or Conservator Information

First Name:	Last Name:	Phone Number:

Please give any additional information that may be important or beneficial in your treatment:
Email
This field is for validation purposes and should be left unchanged.