Janet M. Kinney, Ph.D.  2911 S A.W. Grimes Blvd. STE 750, Pflugerville, TX 78660   512-983-6875

Adult History Form

Name _______________________________________________  Date ___________________

Address _____________________________________ City ___________________ Zip ____________

Phone _________________________ Date of Birth _____________________ SSN __________________

Email ________________________________________________________________________________

Emergency Contact _______________________________________ Phone _______________________

Problem Assessment

What has led you to seek counseling at this time:______________________________________________
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When did these problems develop:__________________________________________________________
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Suicidal/Homicidal Ideation:
Have you attempted suicide:____Yes ____No If yes, how long ago was the last attempt: __________
Do you have current thoughts of ending your life: _____ Yes _____ No
If yes, do you have a plan: ___________________________________________________________

Support System:
Who can you count on for support: (please check all that apply)
___ Parents ___ Spouse ___ Self Help Group ___Employer ___ Church
___ Therapist ___ Neighbor ___ Extended Family ___ Close Friend ___ Pastor
___ Siblings ___ Co-Worker ___ Medical Doctor ___ Other: ___________________________

Symptoms and Specific Problem Areas: (Please check any that are currently troubling you)
___ Abortion/Adoption ___ Depression ___ Legal issues ___ Religion/Faith issues
___ Addictions ___ Divorce ___ Loneliness ___ Separation
___ Alcoholism ___ Eating disorder ___ Loss of appetite ___ Sexual abuse/rape
___ Anger ___ Envy/Jealousy ___ Loss of control ___ Sexual addiction
___ Anxiety ___ Family issues ___ Loss of concentration ___ Sexual issues
___ Apathy ___ Father Issues ___ Loss of energy ___ Single parent
___ Bitterness/resentment ___ Fear ___ Loss of memory ___ Singleness
___ Burnout/stress ___ Finances/debt ___ Loss of sleep ___ Spouse abuse
___ Change of lifestyle ___ Forgiveness ___ Loss of temper ___ Substance abuse
___ Child abuse ___ Frustration ___ Loss of trust ___ Suicidal thoughts
___ Children/discipline ___ Guilt ___ Marriage ___ Self-esteem
___ Children/school ___ Health/medical ___ Medication/drug issues ___ Rejection
___ Children/rebellion ___ Homosexuality ___ Mid-life ___ Unemployment
___ Communication ___ Honesty ___ Mother issues ___Violence/rage
___ Confusion ___ Infidelity ___ Panic attacks ___ Withdrawal
___ Crisis/conflict ___ In-laws ___ Physical abuse ___ Worry
___ Death of loved on ___ Job problems ___ PMS/hormones
Marriage and Family

Marital Status: ___ Single ___ Engaged ___ Married ___ Separated ___ Divorced
How long divorced __________ Number of divorces _____ Length of current Marriage _____
Spouses name __________________________ Age _____ Occupation ______________________
Describe your relationship with your Spouse ___ Excellent ___ Good ___ Fair ___ Poor ___ N/A
Describe your communication with your Spouse ___ Excellent ___ Good ___ Fair ___ Poor ___ N/A

Please tell me about your children

1) Name _______________ Age _____Sex _____ 2) Name ______________Age _____Sex _____
Biological Adopted Step Foster Relative Other Biological Adopted Step Foster Relative Other
Does this child live with you __________ Does this child live with you __________
Physical disability? _____ Learning disability?____ Physical disability? _____ Learning disability?____
Describe your relationship with this child: Describe your relationship with this child:
___ Excellent ___ Good ___ Fair ___ Poor ___ Excellent ___ Good ___ Fair ___ Poor

3) Name _______________ Age _____Sex _____ 4) Name ______________ Age _____Sex _____
Biological Adopted Step Foster Relative Other Biological Adopted Step Foster Relative Other
Does this child live with you __________ Does this child live with you __________
Physical disability? _____ Learning disability?____ Physical disability? _____ Learning disability?____
Describe your relationship with this child Describe your relationship with this child
___ Excellent ___ Good ___ Fair ___ Poor ___ Excellent ___ Good ___ Fair ___ Poor

Family History
Mother: Living, age ______ Died at age ______ How old were you at her death?_______
Describe your relationship with your Mother ___ Excellent ___ Good ___ Fair ___ Poor ___ N/A Father : Living, age ______ Died at age ______ How old were you at his death?_______ Describe your relationship with your Father ___ Excellent ___ Good ___ Fair ___ Poor ___ N/A
Describe their relationship: ___ Very happy ___ Happy ___ Ok ___ Unhappy ___ Very Unhappy ____N/A
Were your parents divorced? ___ Yes ___ No How old were you?_______
Do you have stepparents? ___ Yes ___ No
Describe your relationship with your Stepparents ___ Excellent ___ Good ___ Fair ___ Poor ___ N/A
What was your birth order: ___ of ___ children. How many brothers? ______ How many sisters? ______
Describe your relationship with your Siblings ___ Excellent ___ Good ___ Fair ___ Poor ___ N/A
How would you describe your childhood _________________________________________________
Any family history of depression, anxiety, bipolar or other mental health issue? ___ Yes ___ No Explain:
Educational History

What was school like for you? ______________________________________________________________
Highest level achieved? __________________ What type of grades did you make? ____________________
What was your favorite subject? _______________ What was your least favorite subject? __________________

Occupation

Are you currently employed? ___ Yes, full time ___ Yes, part time ___ No
Employer ________________________________ Occupation ________________________________
What do you like/dislike about your employment/career?
Likes Dislikes
______________________________________ __________________________________________
______________________________________ __________________________________________
______________________________________ __________________________________________

Would you enjoy doing this job on a long-term basis? ___ Yes ___ No
Have you ever been fired? ___ Yes ___ No If yes, please explain_____________________________________

Legal History

Have you ever been charged with a crime other than minor traffic violations? ___ Yes ___ No
If yes, please explain __________________________________________________________________
Have you ever been involved in domestic violence? ___ Yes ___ No
If yes, please explain __________________________________________________________________

Health History

In general, my health is ___ Excellent ___ Good ___ Fair ___ Poor
Date of your last physical exam? ____________ Are you currently under a doctor’s care? ____ Yes ___ No
Do you use tobacco? ____ Yes ____ No If yes, how many packs per day?_____
The nutritional value and balance of your diet is ___ Excellent ___ Good ___ Fair ___ Poor
How often do you exercise? ____Daily _____2-4 times per week ____Occasionally _____Rarely
Has your weight change in recent months? ____ Yes ____ No If yes, how many pounds? _____
How much sleep do you get? ____ hours of what quality ___ Good ___ Fair ___ Poor
Any trouble with sexual functioning? ____ Yes ____ No If yes, explain ___________________________
Name of medications you take Dosage/frequency Reason
____________________________________ _____________________________________ _____________________________________
____________________________________ _________________________ _________________________
_________________________ _________________________ _________________________
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List any current or previous health concerns (attached additional sheet if necessary):
________________________________________________________________________________________________________________________________________________________________________________
Have you been to a counselor before? ___ Yes ___ No
If yes, where? __________________________ Dates ___________________ Number of sessions ______
Any psychiatric hospitalizations? ___ Yes ___ No
Previous use of anti-anxiety, anti-depressant, ADHD, or anti-psychotic medication? ___Yes ___ No
If yes, what and when? _________________________________________________________________

Substance Abuse

Do you use alcohol or drugs? ___ Alcohol ___ Drugs ___ both ___ I don’t use alcohol or drugs
If you use alcohol or drugs, how often do you use them?
___ Every day ___ Several times per week ___ Several times per month
___ Once or twice a month ___ Several times per year ___ Once a year
Other (explain) ________________________________________________________________________
Have you ever felt you should cut down on your alcohol, prescription drugs or other drug use? ___ Yes ___ No
Has a friend or relative discussed concerns about your use? ___ Yes ___ No
Have you had to take a drink or use a drug the next day to steady your nerves? ___ Yes ___ No
Are you a recovering/ recovered alcoholic or drug addict? ___ Yes ___ No
Is there a history of problems with alcohol or drug use in your family? ___ Yes ___ No

Religious/Cultural Factors

Are spiritual or religious issues important to you? ___ Yes ___ No
What is your religion? _____________________ Name of Church _______________________________
How important is your religion to you? ___Not at all ___Slightly important ____Important ___Very important
Describe how you feel about your spiritual life:
___ Very happy ___ Happy ___ Ok ___ Unhappy ___ Very Unhappy ___N/A

Please list any issues that are important or may have affected you in regard to religion or cultural background
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Your Signature Date

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Janet M. Kinney, Ph.D. Date