Elizabeth A. Bowman, Ph.D.

Clinical Psychologist

185 Madison Avenue, 15 Fl

New York, New York 10016

Phone:  (917) 991-0492

 

CONFIDENTIAL BACKGROUND QUESTIONNAIRE

                                                                                                                                                Rev. 3/25/05

Name:  _______________________________________________  Date:________________________

 

Address:____________________________________________________________________________

 

Telephone:   Work:________________ Email:_______________________   Cell:__________________ 

 

Age:_______________    Date of Birth:______________  Referred by:____________________________

 

Gender:          

Marital Status:     Single            Married            Divorced         Separated         Widow

 

Emergency Contact:    _________________________________________________________________

                                    

________________________________________________________________

 

PRESENTING PROBLEM

Please state briefly what brings you for treatment:

 

 

Briefly describe the history of these problems (when did they start, how have the problems changed over time):

 

 

MENTAL HEALTH HISTORY

Have you ever been diagnosed with a mental illness (please provide diagnoses and dates)?

 

 

Do you receive, or have you previously received mental health treatment? ____Yes  ___No (If no, skip to Medical Information section)      (If you are unsure of exact dates, please give approximate dates).

Please list current and previous psychotherapy treatments.  Please describe the reason you sought treatment and any benefit you may have experienced. 

 

 

Do you currently take psychiatric medications?  ____Yes  ___No

If yes, name of current prescribing MD: _____________________________________________

MD’s address and phone number: __________________________________________________

 

 

Please list the names and dosages of all psychiatric medications you are taking.  

 

 

Please list any other psychiatric medications you have previously taken and your response to these medications.

 

 

Have you ever been hospitalized for mental illness?  Please provide date(s) of any reason(s) for admission.

 

 

Have you ever had psychological testing for learning or emotional difficulties?  If yes, indicate (1)dates of testing, (2)reasons for testing, and (3)results of testing (if known).

 

 

MEDICAL INFORMATION

Do you have any present, or past, major medical condition?  __Yes __No    If yes, briefly describe.

 

 

Are you currently taking any medication for a non-psychiatric medical condition?  If yes, please list medication(s) and dosages below. 

 

Please describe any history of hospitalizations for medical illness (please include dates and reasons)? 

 

 

Please describe any relevant family history of major medical illness?

 

 

Who is your primary care physician? Name:_____________________  Phone:__________________        

Address:_______________________________________________ Date of last visit:______________

           

EDUCATION, SOCIAL ASSESSMENT & CURRENT LIVING SITUATION

What is your highest level of education (dates, degrees, school attended, the field of study)?

 

How have you traditionally performed academically?  Do you have any current or past school problems? (Include any history of learning disorders, behavioral problems, or special placement for learning problems.) 

 

 

Are you currently working? __Yes __No.  If yes, list your current position and length of employment.  If no, when is the last time you worked?

 

 

List any entitlements you currently receive (SSI, Food Stamps, Medicaid, Section 8 housing, etc.).

 

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How do you typically structure your time/day (work, sleep, socializing, group activities, TV, school, etc.)?

 

 

Please list some of your hobbies and interests.

 

 

Please describe your religious beliefs or practices. 

 

 

Briefly describe your current living situation (where you live, who else lives there, neighborhood).

 

 

Please describe any past or current involvement with the legal system (lawsuits, arrests, time served). 

 

 

RELATIONSHIPS AND SEXUALITY

Are you currently in an intimate relationship(s)?  If yes, please describe level of satisfaction.  Are you aware of any problematic relationship patterns or other interpersonal issues to address in treatment?

 

 

Do you have children?  __Yes __No    If yes, please state their age, gender, and the status of your current relationships with them.

 

 

How do you identify your sexual orientation?_________________________  Briefly mention any gender or sexual identity issues you may feel important to address in treatment.

 

 

Please describe any problems you may be experiencing with sexual functioning? 

 

 

Briefly describe your current social network (friends, family, co-workers) and your level of satisfaction your current social functioning.

 

 

FAMILY HISTORY

Please identify and briefly describe each person in the household of your family-of-origin (father, mother, stepparent, siblings, others).

 

 

Briefly describe your parents'/caretakers' occupations and education levels.

 

 

Briefly describe your parents’ marital relationship and history.

 

 

Please describe any history of mental illness in your family?

 

 

How are your current relationships with significant family members (e.g. mother, father, stepparent, etc.)?

 

 

ALCOHOL AND SUBSTANCE USE

How often do you currently drink and/or use recreational drugs?  Describe how often, how much, and approximate start dates of use.

Substance_______________  How often?_______________ How much?______________ Start date?_______

Substance_______________  How often?_______________ How much?______________ Start date?_______

Substance_______________  How often?_______________ How much?______________ Start date?_______

 

Do you believe alcohol or substance use has a negative impact on your current functioning (mood states, health, relationships, work, or school performance)?

 

 

Please describe any past history of problem usage?

Substance_______________  How often?_______________ How much?______________ Start date?_______

Substance_______________  How often?_______________ How much?______________ Start date?_______

Substance_______________  How often?_______________ How much?______________ Start date?_______

 

Please describe any history of problem alcohol/drug use in your family?

 

 

TRAUMA HISTORY (please note BRIEFLY here, to be carefully discussed in the future)

Did you experience any premature losses?

 

 

Do you have a history of traumatic illnesses, hospitalizations, injuries, or accidents?

 

 

Did you experience any verbal and/or emotional abuse?

 

 

Do you believe that you experienced neglect from others (especially adults) at any time during your life?

 

 

Do you have a history of sexual trauma?

 

 

Do you have a history of physical trauma or abuse (include experiences of harsh discipline)?

 

 

Have you ever been physically and/or sexually abusive to another person?

 

 

HIGH-RISK BEHAVIORS

Do you currently have thoughts about suicide?  __Yes __No   If so, do you have a plan?  Explain.

 

 

Is there a history of suicide in your family?  __Yes __No

 

 

Do you currently have thoughts about harming others?  __Yes __No    If so, do you have a plan?

 

 

Do you engage in risky or self-injurious behaviors (cutting, dangerous sexual behaviors, other) __Yes __No

 

 

Do you ever lose control of your anger and act impulsively?  If yes please describe.   

 

 

PSYCHIATRIC SYMPTOMS  

How would you describe your mood (i.e. depressed, anxious, up and down, highly sensitivity/reactive to others)?

 

 

Have you ever had periods of time where you had too much energy?

 

 

How would you describe your self-esteem?

 

 

How often do you worry?  What kind of things do you worry about?

 

 

Do you ever have episodes of sudden, intense worry or panic?

 

 

Do you ever have repetitive, irrational, worrying thoughts that you feel you cannot control?

 

 

Do you ever feel compelled to engage in behaviors that give you relief from worry (i.e., checking, cleaning, hand washing, other rituals)?

 

 

Do you have problems with sleep?  In general, how many hours of sleep you get per night: _______

 

 

Do you ever feel suspicious that people are talking about you or want to hurt you?  Do you have a difficult time trusting people?  If yes, explain.

 

 

Do you ever hear things other people don’t hear or see things other people don’t see?  If yes, explain.

 

 

Do you ever feel unreal or disconnected from your feelings, thoughts, or body?  Do you ever enter into trance-like states?

 

 

Do you have any difficulties with memory?

 

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Please describe any areas of concern or issues that have not been addressed?

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How do you hope to benefit from psychotherapy?

 

 

Thank you for your time and attention in providing this information.