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Home
Counselors
Career Opportunities
Employment Services
Pay Bill
Donate
Foundation Board
About/Contact Us
New Horizons
Mental Health
Addictions
Serenity Hills
C.A.R.E.
NEPRC
Adult Questionnaire
Click here for a printable PDF
Name:
First
Middle
Last
Birthdate:
Address:
Phone:
Email:
Gender & pronoun preference:
Have you ever served in the armed forces?
Yes
No
Do you consent to receive occasional texts and emails? (This will be limited to appointment reminders, cancellations, etc.)
Yes
No
Who is your cell phone provider?
What are your reasons for being seen today?
Previous Counseling/Psychiatric/Addictions treatment:
Past Psychiatric Histroy - for yes answers, obtain ROI
Have you ever had therapy/counseling for mental health/addictions?
Yes
No
If yes, when, with whom & was it helpful?
Have you ever seen a psychiatrist?
Yes
No
If yes, when, with whom & what was your diagnosis:
Have you ever been hospitalized in a psychiatric hospital?
Yes
No
If yes, why, where, when, and for how long:
Have you ever hurt yourself or tried to commit suicide?
Yes
No
If yes, by what means?
Are you currently experiencing suicidal ideation?
Medical:
Who is your primary care provider and at which clinic is he/she employed?
What is your preferred pharmacy and location?
What current medical conditions do you have and what past surgeries have you had?
What are your current medications and dosages? Include anything over the counter. Also note any negative side effects:
Please list any allergies, particularly any allergies to medications:
Have you ever had a head injury?
Yes
No
Have you ever had a seizure?
Yes
No
History of abuse?
Yes
No
History of trauma?
Yes
No
FEMALES
Are you currently pregnant?
Yes
No
Do your symptons happen or worsen before your menstrual cycle?
Yes
No
Are you currently taking birth control:
Yes
No
Family History:
Marital Status
Single
Married
Divorced
Widowed
Ages of Children:
List siblings, ages, and history of mental illness or addictions
Summarize your parents' health history, including mental health diagnosis:
Substance use History:
Please check the box next to any substances you have used, and fill out the corresponding fields.
Alcohol:
Last Use:
How often/how much:
Nicotine:
Last Use:
How often/how much:
Caffeine:
Last Use:
How often/how much:
Marijuana:
Last Use:
How often/how much:
Cocaine/Crack:
Last Use:
How often/how much:
Heroin:
Last Use:
How often/how much:
LSD:
Last Use:
How often/how much:
Methamphetamine:
Last Use:
How often/how much:
Fentanyl/Opioids:
Last Use:
How often/how much:
Other:
Last Use:
How often/how much:
Have you ever detoxified when quitting alcohol use?
Yes
No
Personal background:
When and from where did you graduate from high school or earn your GED? Also list any post-secondary education:
Summarize your work history:
Hobbies or social activities:
Religious preference:
Do you have any current or "past" legal charges? If so what? Who is your attorney and/or corrections officer?
What are your strengths:
What are your treatment goals you'd like to achieve?
Is there anything else you would like to discuss today?
