Janell W. Harvey, LPC,
805 Holcomb Boulevard
Ocean Springs, MS 39564
Appointment: 228 324-5767 Counselor: 228 326-2023
Islands Counseling Effective Date: 06/30/05
jharvey@islandscounseling.com www.islandscounseling.com
Adult Information Checklist
Name: __________________________________________________________
The following are common concerns of individuals. Please check all that apply to you.
1. My family has a history of (check all that apply):
__ poor communication __ counseling __ abuse
__ depression __ hospitalization __ alcoholism
__ eating disorders __ drug or gambling addiction
2. I use alcohol:
__ less than once per week __ more than once per week __ never
3. I use drugs:
__ less than once per week __ more than once per week __ never
4. The following have resulted from my use of alcohol/drugs (check all that apply):
__ traffic violation __ black outs __ financial problems
__ ruined relationship __ health problems __ work or academic problems
5. __ I have been in trouble with the legal system.
6. __ I have had an unwanted sexual experience.
7. I have experienced (check all that apply):
__ emotional abuse __ sexual abuse __ physical abuse
8. I've tried to control my weight with (check all that apply):
__ vomiting __ laxatives __ not eating
__ diet pills __ excessive exercise __ other
9. I have thought or tried to (check all that apply):
__ harm myself __harm another person
10. __ At times, I have acted in a violent manner.
11. I have recently had problems with the following (check all that apply):
__ sleeping __ appetite __ fatigue
__ concentration __ weight loss/gain __ mood shifts
__ headaches __ anxiety __ medical problems
12. I have difficulty (check all that apply):
__ expressing my emotions __ controlling my anger __handling stress
__ accepting myself __ accepting compliments
13. I have experienced a recent (check all that apply):
__ death __ relationship that ended __ major move
14. __ Sometimes I hear unwanted voices in my head.
Information Checklist (Adult)
Name: ______________________________________________________________
FOR EACH ISSUE, PLACE A CHECK UNDER THE NUMBER TO DECIDE HOW MUCH EACH ISSUE HAS DISTRESSED, WORRIED, OR BOTHERED YOU IN THE PAST TWO WEEKS.
1-Not at all 2-SIight 3-Moderate 4-Considerable 5-Extreme
1 Feeling angry 1 2 3 4 5
2 Feeling timid or shy 1 2 3 4 5
3 Feeling depressed 1 2 3 4 5
4 Being easily embarrassed 1 2 3 4 5
5 Feeling like a failure 1 2 3 4 5
6 Feeling on the verge of tears 1 2 3 4 5
7 Being ill at ease with others 1 2 3 4 5
8 Feeling discouraged 1 2 3 4 5
9 Not feeling like eating 1 2 3 4 5
10 A lack of friends 1 2 3 4 5
11 Feeling shy with the opposite sex 1 2 3 4 5
12 Blame, criticize or condemn others 1 2 3 4 5
13 Difficulty holding conversations 1 2 3 4 5
14 Feeling hopeless 1 2 3 4 5
15 Headaches 1 2 3 4 5
16 Difficulty with Sleep 1 2 3 4 5
17 Stay by yourself a lot 1 2 3 4 5
18 Feeling tense and nervous 1 2 3 4 5
19 Upset stomach 1 2 3 4 5
20 Sexual problems 1 2 3 4 5
21 Suicidal thoughts 1 2 3 4 5
22 Problems with family 1 2 3 4 5
23 Upset by academic concerns 1 2 3 4 5
24 Problems with spouse or significant other 1 2 3 4 5
25 Stress related to work 1 2 3 4 5
26 Stress related to school 1 2 3 4 5
27 Being overweight 1 2 3 4 5
28 Problems with anxiety 1 2 3 4 5
29 Unhappy with living arrangements 1 2 3 4 5
Please indicate how important spiritual and religious issues are in your life. _________________________________________________________ _________________________________________________________
How much do spiritual and religious concerns affect your daily decision making?____________________________________________________________________
_____________________________________________________________________
List all persons living in the home including age and relationship to you. _____________________________________________________________________
_____________________________________________________________________
List all current medications you are taking including dosage, reason for taking the medication, and the physician who prescribed the medication. __________________________________________________________________________________________________________________________________________
In order of importance, list the goals you have for counseling? Please be as specific as possible.
1.___________________________________________________________________
2.___________________________________________________________________
3.___________________________________________________________________
How many total sessions do you anticipate you will need to accomplish these goals?
1__ 2-4 __ 5-8 __ 9-12 __ 13-15 __ 16+__
Circle the number that best describes how much your concerns are interfering with your personal functioning.
(Not at all) 0 1 2 3 4 5 6 7 8 9 10 (A great deal)