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Home
Overview
Mental Health Disorders
Depression Anxiety
Generalized Anxiety Disorder (GAD)
Panic Attacks
Obsessive-Compulsive Disorder (OCD)
Emetophobia
ADHD
Aspergers Syndrome
Learning Disabilities
Forms of Therapy
Cognitive Behavioral Therapy (CBT)
Dialectical Behavioral Therapy (DBT)
Eye Movement Desensitization and Reprocessing (EMDR)
Biofeedback
Internal Family Systems (IFS)
Types of Therapy
Individual therapy for adults and children
Social Sense Program
Couples Therapy
Family Therapy
Workshops & Trainings
Telehealth Services
Articles
Forms
Client History Form
Janneta Bohlander & Associates, LLC
Janneta Bohlander, LMFT
83 East Avenue, Suite 208
203-521-0805
Janneta Bohlander, LMFT
CT license number 000955
Tax ID 20-3204106
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Personal History Form
Client Name:
*
Preferred Pronoun:
Date:
Birth date:
Age:
Referral Source:
Medical Provider:
Insurance Provider:
My Website: jbohlander.com
Psychology Today
Friend/Family:
Other:
Form completed by:
Client
Other:
Cell phone number:
Home Phone number:
Email:
*
OK to leave message?
Phone
Email
Have you previously received any type of mental health services?
Yes
No
If yes, which of the following:
Psychotherapy
Medication
Outpatient Hospitalizations
Inpatient Hospitalization
If yes, please provide: Name of provider or facility:
Location:
Dates of treatment:
Reason for treatment:
Briefly, what brings you in today:
How long have you had the current problem(s)?
When did your problem first start?
Within the last: 30 days
6--12 months
2 years
During adolescence
During childhood
What areas of your life have been affected because of this problem?
How stressful is this to you?
Minimal
Mild
Moderate
Severe
How have you attempted to cope with this problem?
What are your symptoms?
sleep disturbance
low interest/motivation
energy level
thoughts of self-harm/suicide
appetite problems
concentration problems
hopelessness
nightmares
panic attacks
OCD symptoms
anxiety
flashbacks
Other:
What effect do these symptoms have on your life?
Minimal
Mild
Moderate
Severe
Please describe any major losses or traumas you have experienced:
What are your past/present and future stressors?
Deaths
Physical/sexual abuse
Alcohol/drug abuse
Psychiatric illness
Divorce
Frequent relocations
Serious illness
Attempted/completed suicide
Legal problems
Debilitating injuries/disabilities
Financial crisis/unemployment
Do you regularly use alcohol?
Yes
No
In a typical month, how often do you have 4 or more drinks
How often do you engage in recreational drug use?
Never
Rarely
Monthly
Weekly
Daily
Do you consider this alcohol/drug use a problem?
No
Yes
Unsure
Are there cultural considerations that need to be taken into consideration in your treatment?
Yes, Please specify
No
Have you experienced abuse?
None
Unsure
Emotional
Physical
Sexual
At what age?
By whom?
Family History
Please list your parents and siblings. Please use additional space on the back if needed
Name
Age
Relationship
Where do they live?
If deceased, age and cause
Name
Age
Relationship
Where do they live?
If deceased, age and cause
Name
Age
Relationship
Where do they live?
If deceased, age and cause
Name
Age
Relationship
Where do they live?
If deceased, age and cause
Who did you live with while growing up?
Mother's occupation:
Father's occupation?
In general, how would you describe your childhood?
Very happy
Mostly happy
Average
Unhappy
Very unhappy
Why?
Who do you consider a source of support for you?
In the section below identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (father, grandmother, uncle, etc.).
Condition
Alcohol/Substance Abuse
Anxiety
Depression
Domestic Violence
Sexual Abuse
Eating Disorders
Obesity
Obsessive Compulsive Disorder
Schizophrenia
Suicide Attempts
Other diagnosed mental health condition?
Please circle
Yes
No
List Family Member
Marital Status:
Never Married
Domestic Partner
Married
Separated Divorced -- For how long?
Widowed: Please provide your partners name and year deceased:
If married, how long have you been married for and what is your partners’ name
On a scale of 1-10 (best), how would you rate your relationship?
Are you currently in a romantic relationship?
Yes
No
How long?
On a scale of 1-10 (best), how would you rate your relationship?
Please list any children, their names, and ages:
Name
*
Age
Relationship
Name of other parent
If deceased, age and cause of death
Name
*
Age
Relationship
Name of other parent
If deceased, age and cause of death
Name
*
Age
Relationship
Name of other parent
If deceased, age and cause of death
Prescribing provider and contact information:
Name:
*
Specialty:
*
Facility:
*
Phone, email, or Fax:
*
How would you rate your current physical health?
Poor
Unsatisfactory Satisfactory
Good
Very Good
Please list any specific health problems you are currently experiencing
How would you rate your current sleeping habits?
Poor
Unsatisfactory Satisfactory
Satisfactory
Good
Very Good
If you are having problems, in which phase of sleep are you experiencing issues?
Falling asleep
Staying asleep
Awakening early
Sleep apnea
Please list any other specific sleep problems you are currently experiencing:
How many times per week do you generally exercise?
What types of exercise do you participate in:
Are you currently experiencing any chronic pain?
No
Yes
If yes, please describe:
Additional Information:
What do you enjoy about your work (full-time homemaker included)?
If retired, what did you enjoy about your work?
What do you find particularly stressful about your current or previous work?
What do you enjoy doing in your free time? What do you do to relax?
Do you consider yourself to be spiritual or religious? If yes, please describe your faith or belief :
What do you consider to be some of your strengths?
What do you consider to be some of your weakness?
What do you hope to achieve through treatment? My goals for therapy are:
1
2
3
4
5
How optimistic are you that your concern(s) can be addressed?
Not at all
Mildly
Moderately
Highly
Submit
