Cynthia M Chase

The following forms may be sent to me at cynthia_chase@sbcglobal.net or brought with you on your first appointment.  Here’s how to do it:  go to edit, select all, copy, then go to send a new email at cynthia_chase@sbcglobal.net, then paste. Fill in the data, and send email back to me.  Another option is to email me your request for an intake form, and I will e-mail it back to you.  I recommend that you send it along first so that we may get started right away at your initial appointment!

CYNTHIA CHASE, MSW, LCSW

DATE:

Please answer the questions below to the extent that you feel comfortable.  Your answers will be helpful in our work together.

Name:

Date of Birth:                                                 Age:

Address:

With whom do you live?

E-mail address:

Telephone/ Home:

Work:

Mobile:

Insurance Information

Insurance Company:

Your name and insurance ID:

Your Social Security number:

Insured Name (if different from you):

Insured ID number:

Insured Social Security Number:

Insured date of birth

Policy or Group Number:

Who referred you to me?

Briefly, what brings you to therapy at this time?

Marital History:

Name of spouse/partner:

Legal status

Years married/together:

Previous marriages/primary relationships:

Number of children:

Names:                                            Ages:

If a woman, are you pregnant?

Number of stepchildren:

Names:                                                     Ages:

(Add names of parents next to the name of each child please)

Religious background (how were you brought up):

Religion of mother:

Religion of father:

Nationality of each of your biological parents (from what country/countries were each of your parents ancestors from? :

Mother:

Father:

Employment History:

Currently Employed?

How long?

Name of Employer:

Address:

Job title:

If unemployed, how long?

Primary source of income:

Occupation:

Summary of work history:

Educational History:

Highest grade completed:

Grammar school/s attended including location:

High School/s including location/s:

College/s attended, including location/s:

Graduate School, including location/s:

Academic performance:

Medical information

Primary Care Physician and address:

Telephone number of physician:

For women, Gynecologist name and address:

Emergency contact name and phone number:

Emotional Health Assessment (Check those that apply and describe):

____Depression____________________________________________

____Anxiety_______________________________________________

____Panic Attacks__________________________________________

_____Fatigue_____Indecisive_____Shortness of breath     (Please check)

_____Feelings of detachment_____Numbness_____Dizziness

____Change/Problem with eating habits_________________________

____Trouble concentrating_______________________________

____Memory problems_______________________________________

____Uncontrollable thoughts or impulses ___________________

____Irrational fears or phobias_________________________________

____Alcohol abuse___________________________________________

____History of alcohol abuse___________________________________

____Drug Abuse ____________________________________________

____History of drug abuse_____________________________________

____Amount, frequency, age of onset and last used: drugs or alcohol___

__________________________________________________________

_____History of sexual or physical abuse_________________________

_____Obsessive thoughts or behavior____________________________

_____Sleep problems_________________________________________

_____Other problems_________________________________________

Medical History:

____Heart Problems__________________________________________

____Diabetes________________________________________________

____Liver disease____________________________________________

____High blood pressure_______________________________________

____Stomach problems________________________________________

____Recent injury or surgery____________________________________

____Thyroid (last time checked)_________________________________

____Other Medical problems_____________________________

___________________________________________________________

Psychiatric and medication history

Previous psychiatric/psychological treatment: Yes:           No:

Current Psychiatrist or APRN, including address and phone number:

Treatment person and title, starting with most recent, and approximate dates of treatment as well as general result:

Medication History

Current Medications:

Name of drug:     dosage:     when prescribed:     by whom:     response:

Previous medications:

Name of drug:     dosage:     when prescribed:     by whom:     response:

Family and history

Parents:

Mother’s name:

Her present age?

Location:

Fathers name:

His age?

Location:

Step-parents:

Step-mother’s name:

Her present age?

Step-father’s name:

His age?

If adopted, biological parents:

Biological mother’s name:

Her present age?

Location:

Biological Father’s name:

His present age?

Location:

Biological siblings including their names, ages and location:

If deceased:

Your age at death of biological mother?

Your age at death of biological father?

Age of your mother at her death?

Age of your father at his death?

Your position in the family (for example, oldest):

Describe your mother briefly:

Describe your father briefly:

Other relatives who were especially important to you when you were    growing up (for example, a grandparent):

Choose three words which would best describe each of your brothers and sisters, if you have any:

Choose three words your family used or might have used to describe you when you were growing up:

Your reaction to beginning school:

Your experience of school thereafter:

Age at your earliest sexual experience:

Your earliest memories:

Most significant person in your life prior to marriage – describe and state why:

Who took primary care of you as an infant?

Describe your early care, including any particular stress during your infancy (for example, hospitalization of you or an individual who took care        of you, losses in the family, divorce, and so on):

Present problem areas

Describe how interaction with others is stressful:

• Marital relationship

• Work:

• Children

• Sexual

• Other:

• Major Present Stressors

Greatest sources of satisfaction:

Any other comments to help me understand you?

CONSENT FOR TREATMENT

I, _____________________________, DATE OF BIRTH_____________, HEREBY GIVE CONSENT FOR CYNTHIA CHASE, CERTIFIED INDEPENDENT SOCIAL WORKER, TO PROVIDE PSYCHOLOGICAL/PSYCHIATRIC ASSESSMENT AND TREATMENT TO:

SELF: ____________________________________AND/OR

NAME OF CHILD: _______________________________

SIGNED: ________________________________________________________________

DATE: __________________________________________________________________