Bend Psychological Services Client/Patient Information

This information is confidential and protected in accordance with State Law

We recommend that you not submit any information on-line or in writing that may be of criminal, violent or destructive nature until you speak with your provider or an attorney.

You are not required to submit this form using the internet. You may:

speak with us and ask that the minimal information be included to our record
complete this form on-line and submit the results by e-mail, or
print this form, complete it by hand and bring it to your first appointment.

Client/Patient Information Form - Adult

Name of Person Completing this form

Your E-Mail

Date of birth

Age

Weight

Height

Color eyes

Color hair

Address(es) (who and where)

Phone(s) (work, home, cell, pagers, how and when to best to contact)

Employment (employer, type of work, days, hours, availability to speak)

How and when you can be reached (how, day, night, emergency, messages)

Martial history (date of marriage, divorces, current marital status, on-going or recurrent problems)

Adoption history (if adopted)

Brothers and Sisters (name, age, by marriage or biological relationship)

School history (drop out, expulsions, suspensions, held back, when, reasons)

Most recent physical (when, purpose, what was done, findings)

Medication allergies (drug name, reaction, treatment)

Current medications (drug name, when, dosage, purpose, name of prescribing physician)

Past medications (when, drug name, purpose, effectiveness, problems)

Current medical problems and treatment (allergies, skin, infections, injury, etc..)

Previous hospitalizations or surgery (when, what for, treatment, how long)

History of major injury or accident (when, what happened, treatment, lasting effects)

Birth history (trauma, complications, problems)

Criminal history (when, arrests, charges, detention, court appearances) (You are not required to reveal behavior at this time that was or may be criminal)

Employment history (when, employer, type of work, problems, successes)

Alcohol, chemical and other drug use (when, used what, how long) (You are not required to submit this information until you speak with your provider.)

Traumatic life experiences (physical, psychological, when, what happened, treatment, lasting impacts)

Therapy or counseling history (when, name of person, title, diagnosis, treatment method, length of treatment, outcome)

Recent or unusual behavior that worries you.

History of destructive, violent, self-harming or suicidal behavior (when, what did your child do, your response, response by others, treatment if any) (You are not required to submit this information until you speak with your provider.)

Psychiatric hospitalization history (when, where, what for, how long, treatment, diagnosis)

Residential treatment history (when, what for, voluntary or mandatory education, treatment, how long, outcome)

Special program history (when, what for, voluntary or mandatory education or treatment, how long, outcome)

Family History

Family issues, problems, conflicts, current or past that affect your life

Family history of psychiatric problems including relatives (who, relationship, diagnosis or disorder, treatment, medications, outcome) (You are not required to submit this information until you speak with your provider.)

Deaths in the family, suicide or accidental loss of life (when, who, relationship, how, impact on family and child) (You are not required to submit this information until you speak with your provider.)

Family history of alcohol, chemical or drug use (who, when, what, how long, treatment, outcome)

Family health (who, medical problems or conditions, when, how long)

Legal problems (what, when, how long, outcome or current status) (You are not required to submit this information until you speak with your provider.)

Custody, visitation or child support issues

Medical History

Has your child ever been treated by a physician for any of the following medical problems.

Cancer	Indigestion
Tension head aches	Vomiting
Migraines	Lower stomach (intestinal problems)
Diabetes	Diarrhea
Thyroid problems	Back problems
Seizure(s)	Heart problems
Tumor(s)	Circulation
Asthma	Kidney problems
Lung disease	Bladder problems
Breathing problems	Liver problems
Ulcer(s)	Eye problem(s)
Stomach problems	Vision problem(s)

Have your child ever been treated by a physician for any of the following medical problems.

Glaucoma

Head injury

Multiple sclerosis

Addison's disease

Lupus

Reoccurring pain

Chronic pain

Other

Please describe the above problems you checked in more detail including current or past treatment and whether or not the problem is currently in remission, managed or under control. You may use as much space as necessary.

Please check those items that describe your history of alcohol or other drug use. (You are not required to submit this information until you speak with your provider.)

Alcohol
Coffee
Other drinks that contain caffeine
Tobacco smoking products
Tobacco chewing products
Marijuana
Methamphetamines
LSD
Crack cocaine
Heroine
Other

Interests and Strengths

Please describe your hobbies, interest and talents

Please describe your education or career interests

Please describe your strength, abilities and positive qualities.

(Be sure you are connected to the internet if you Submit By E-Mail)

Submission by E-mail is no more secure than submission by standard mail services. You may submit this form by mail or in person at your first appointment.