CRT COUNSELING-Change, Renewal, Transition, PA
Client History
Printable - Client History Form
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PRESENTING PROBLEM AS STATED BY CLIENT
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HISTORY OF PRESENTING PROBLEM (ONSET OF PROBLEMS, SYMPTOMS, BEHAVIORS, INCLUDING PSYCHOLOGICAL AND SOCIAL STRESSORS):
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PAST PSYCHIATRIC HISTORY (INCLUDING MEDICINES,ALLERGIES, PAST TREATMENTS, PROVIDER, INTERVENTION RESPONSES):
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FAMILY HISTORY OF SUBSTANCE ABUSE AND MENTAL HEALTH:
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PAST AND PRESENT USE OF CIGARETTES, ALCOHOL/DRUGS (INCLUDE OVER THE COUNTER):
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_____________________________________________________DEVELOPMENTAL HISTORY (PRENATAL AND PERINATAL EVENT FOR CHILDREN AND ADOLESCENTS):
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PAST MEDICAL HISTORY (INCLUDING HOSPITALIZATIONS, SURGERIES. MAJOR ILLNESS, AND MEDICATIONS):_____________________________________________________
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CLIENT'S:STRENGTHS_____________________________________________________
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WEAKNESSES_____________________________________________________
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MEDICATIONS (NOTE FREQUENCY,DURATION,PURPOSE,EFFECTIVENESS & MD WHO PRESCRIBED):
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