protected health information history form...over the last month symptoms have: ___improved...

Laurel Langholz, Ph. D. LLC 1930 St. Andrews Ct. NE Suite D Licensed Clinical Psychologist Cedar Rapids, IA 52402 www.langholzcounseling.com Office 319.320.3211 Secure Fax 319.237.7345

PROTECTED HEALTH INFORMATION HISTORY FORM

Client Name: Today’s Date:

Prefers to be called________________________ Gender ___Male ___Female Birthdate__________________Age______

Address_______________________________________City___________________ Zip_____________Grade_____________

Telephone_______________________________Cell Phone__________________School_____________________________

Parent/Guardian________________________________Cell Phone__________________________Birthdate_____________

Parent/Guardian________________________________Cell Phone __________________________Birthdate_____________

Child’s Physician___________________________ Psychiatrist_____________________Teacher_______________________

Living Arrangement_________________________________________ Legal Custody________________________________

Who referred you to Dr. Langholz_________________________Information Provided By:____________________________ Presenting Concerns Please describe the concerns that prompted you to seek counseling:

Please check any of the symptoms below you have observed over the last 2 weeks: Symptoms: ☐ Depressed/sad mood ☐ Anxiety ☐ Chronic physical pain

☐ Easily discouraged ☐ Social Anxiety ☐ Paranoia

☐ Low self-esteem ☐ Worries hard to control ☐ Agitation

☐ Low energy ☐ Racing thoughts ☐ Easily angered

☐ Shame/self-critical ☐ Perfectionism ☐ Excess energy

☐ Indecisiveness ☐ Phys. symptoms of anxiety ☐ Euphoric mood

☐ Irritability ☐ Panic attacks ☐ Abrupt mood shifts

☐ Lack of enjoyment ☐ Chronic anxious fears ☐ Eating disorder sympt.

☐ Low motivation ☐ Ruminating thoughts ☐ Attachment Concerns

☐ Negative thoughts ☐ Obsessive thoughts ☐ Sleep Initiation

☐ Appetite changes ☐ Compulsive behaviors/rituals ☐ Insomnia

☐ Sleep difficulties ☐ Counting/checking behaviors ☐ Hypersomnia

☐ Chronic guilt ☐ Phobias/Fears ☐ Poor concentration

☐ Apathy ☐ PTSD-intrusive ☐ Impulsivity

☐ Frequent crying ☐ PTSD-avoidance ☐ ADHD symptoms

☐ Hopelessness ☐ PTSD-hyperarousal ☐

☐ Social isolation ☐ Disassociation ☐

Please list any additional symptoms your child is experiencing:

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Laurel Langholz Ph.D. Client History Clinical Psychologist

Describe how these symptoms or concerns impact others in the family, at school, and elsewhere:

Onset

When did symptoms or problems begin?

Duration

Symptoms have: ___consistently persisted since their onset ____have come and gone

____have been present intermittently since they began

Course

Have symptoms or problems changed overtime? Yes or No

Over the last month symptoms have:

___Improved ___Worsened ___Gradually Worsened ___ Rapidly Worsened ___Remained the Same

Precipitating factors Please describe events, losses, stresses, changes, or any other contributing factors

that may be contributing to my child’s concerns:______________________________________________

______________________________________________________________________________________

Please check any of the stresses below that could be affecting your child:

____Parent Conflict ___ Divorce/Separation ____Child or Family member Health Concerns

___Moved ____Learning or Achievement Concerns ___Losses/Death of Relation or Pet

___Peer Conflict ___Bullying ___Socially Isolated ____Shy or Socially Awkward ____Substance Abuse

Family Issues :___Alcoholism, __Mental Illness ___Legal Troubles ___Physical/Sexual/Emotional Abuse

Please explain in further detail the items selected above: ____________________________________

____________________________________________________________________________________

How much impairment in functioning has occurred in these areas?

(N) None (M) Minimal (S) Significant

Activities of daily living ___ Behavior at school_____ Homework completion____

Academic functioning_______ Social Functioning______________

Interpersonal Relationships______ Cognitive Functioning- ___memory __ concentration,

Physical Health___ __ organization ___problem solving ___decision making ___impulsive

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Vegetative Functioning- Check those areas below that have been significantly affected:

___Sleep ___Fatigue ____Appetite ___Fluctuations in weight ___Energy Level ___ Concentration

___Arousal/Alertness ___Motivation ____ Enjoyment of Activities

Please indicate your child’s risk for any of the following:

Potential for Alcohol Abuse ☐ Denied ☐ Past ☐ Present

Potential for Drug Abuse ☐ Denied ☐ Past ☐ Present

Potential for Running Away ☐ Denied ☐ Past ☐ Present

Potential for Eating Disorder ☐ Denied ☐ Past ☐ Present

Potential for Aggression ☐ Denied ☐ Past ☐ Present

Potential for Self-Injury ☐ Denied ☐ Past ☐ Present

Potential for Suicide ☐ Denied ☐ Past ☐ Present

Please describe in detail any areas of risk you marked above:

Please share any details you can to help me understand your child’s risk for suicide and self-harm:

Does anyone in your family have a history of attempted suicide? Yes or No If yes,

who:_________________

Please explain:______________________________________________________________________

When did this occur?

Has your child ever engaged in suicidal behavior, self-harm, cutting, or high risk behavior? Yes or No

If yes, when did this occur?_________________________

Please explain the details of past and present self-harm: ______________________________________

_____________________________________________________________________________________

Has your child expressed a wish to die or intention to hurt him/herself? Yes or No

When is the last time he or she has verbalized this idea?________________________________________

To whom did your child express this wish or idea?_____________________________________________

What were the circumstances or events in your child’s life at the time that may have contributed to this

intention?

Who does your child perceive as a source of support to him or her?

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Current Physical Health and Medical History

Please describe your child’s current health:

Please list any and all medical concerns, conditions, or medical diagnosis for which your child is currently

being treated or is experiencing:

Please list any known allergies: ___________________________________________________________

_____________________________________________________________________________________

Health Habits

How often does child exercise: ___Never ___1-2 times a week ___3 or more times a week.

Child’s preferred or usual types of exercise: ________________________________________________

How active is child’s daily life? ___Sedentary ___Mildly Active ____Moderately Active ___Very Active

Describe child’s food choices: ____balanced ____very healthy ___high fat ____high sugar

Describe child’s eating habits: __Under eats __Over eat __Moderately eat ___Has very little appetite

____Frequently diets ___Is constantly watching weight ____Eating seems out of control

____Skips meals ____Snacks a lot ____Eats many small meals ____Eats 3 meals a day

How many hours of sleep child typically gets: ____10 or more ___8-9 ___6 or less hours nightly

Your child’s quality of sleep: _ __Falls asleep promptly ___Sleeps all night with little disturbance

___Has trouble falling asleep ____Wakes up several times a night ___Awakens very early in the morning

Once child is out of bed, he or she seems:

___Rested and energetic ___Appears fatigued and lacking energy ___Pleasant ___Irritable ___Neutral

How often does child use:

Tobacco ___never ___occasionally ___frequently ___daily

Alcohol ___never ___once a month ___once a week ___1-2drinks a day ___>2 drinks a day

Caffeine ___never ___once a month ___once a week ___1 serving daily ___ 2-3 servings daily

Other illegal or prohibited substances: ___________________________ Frequency______ Onset_____

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Medical History Please list previous significant or frequent medical conditions for which the child has been treated: Year Treated Condition Treated __________ _______________________________________________________________________

__________ _______________________________________________________________________

__________ _______________________________________________________________________

__________ _______________________________________________________________________

__________ _______________________________________________________________________

Hospitalizations

Please list previous hospitalizations, medical & psychiatric, and the year child was hospitalized: Year Hospitalized Reason for Hospitalization __________ _______________________________________________________________________ __________ _______________________________________________________________________ __________ _______________________________________________________________________

Injuries or Accidents:

Please list previous significant injuries or accidents sustained by your child and when they occurred: Year Injured Type of Injury or Accident __________ _______________________________________________________________________

__________ _______________________________________________________________________

__________ _______________________________________________________________________

Is your child accident prone? Yes or No Is your child clumsy or lacking coordination? Yes or No

Current Medications/Supplements:

Please list all currently used prescribed medications or supplements

Medication Reason for Use Dosage Unsure of exact dosage amount

____________________ __________________ _______________________ ☐ ____________________ _________________ _______________________ ☐

_____________________ _________________ _______________________ ☐

_____________________ _________________ _______________________ ☐

Please list any previous medications that your child has been on for a sustained period of time:

______________________________________________________________________________________

______________________________________________________________________________________

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Indicate family relatives of the child with a history of any of the following:

Child’s

Mother

Child’s

Father

Sibling Maternal

Relative

Paternal

Relative

Major Depression ☐ ☐ ☐ ☐ ☐

Manic Episode ☐ ☐ ☐ ☐ ☐

Bipolar Disorder ☐ ☐ ☐ ☐ ☐

Mood Swings ☐ ☐ ☐ ☐ ☐

Generalized Anxiety ☐ ☐ ☐ ☐ ☐

Phobias/Excessive Fears ☐ ☐ ☐ ☐ ☐

Social Anxiety/Severe Shyness ☐ ☐ ☐ ☐ ☐

Obsessive Compulsive Disorder ☐ ☐ ☐ ☐ ☐

Anger Management Concerns ☐ ☐ ☐ ☐ ☐

Schizophrenia ☐ ☐ ☐ ☐ ☐

Social Avoidance ☐ ☐ ☐ ☐ ☐

Alcoholism ☐ ☐ ☐ ☐ ☐

Drug Abuse ☐ ☐ ☐ ☐ ☐

Domestic Violence ☐ ☐ ☐ ☐ ☐

Physical Abuse ☐ ☐ ☐ ☐ ☐

Sexual Abuse ☐ ☐ ☐ ☐ ☐

Attention Deficit Hyperactivity ☐ ☐ ☐ ☐ ☐

Any Further Explanation:

Previous Mental Health Evaluation & Treatment:

Please list and describe previous mental health evaluations and testing, and results/diagnosis:

Year Physician/Psychologist Findings

__________ ______________________ ______________________________________________

__________ ______________________ ______________________________________________

__________ ______________________ ______________________________________________

Please list all previous mental health treatment child has experienced: Was treatment

Year Treatment Provider Reason or Focus of Treatment helpful Y OR N

__________ ______________________ _________________________________________ ___

__________ ______________________ _________________________________________ ___

__________ ______________________ _________________________________________ ___

Social History

With whom does the child live?

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If parents are divorced, please describe child’s visitation schedule and living arrangements, as well as any

problems or adjustments the child may be confronting due to the visitation arrangement:

Parents are: ____married ____ date married_____________ # of years married:_________

____divorced ___separated , Father remarried Y or N Mother remarried Y or N

If parents separated or divorced, how old was child when parents separated: _______

Does child see both parents? _____Yes or ____No

Is either parent deceased? Yes or No If yes, ____Mother or _____Father

How old was the client at the time of parent’s death?________

Describe the quality of the relationship between the child’s biological mother and biological father:

(Communication / conflict / compatibility / closeness, affection etc.)

If parents are separated, how well do biological parents co-parent their child? Describe any concerns:

If parents are divorced and remarried, please describe the quality of the relationship between:

Mother and Stepfather:

Father and Stepmother:

How well does the child relate to his or her stepparents? Please describe in detail:

Child’s Biological Mother

Mother’s Name_____________________________Age_______Occupation______________________

Years of education_______ ___Living or ___Deceased _______ Marital status_________________

If deceased, year or child’s age at the time____ Where does parent live:_________________________

Describe child’s relationship with this parent figure:

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Has the child ever been separated from biological mother? Yes or No

If yes, please describe timeline, reasons, and circumstances around separations:

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Child’s Biological Father

Father’s Name_____________________________Age_______Occupation______________________

Years of education_______ ___Living or ___Deceased _______ Marital status_________________

If deceased, year or child’s age at the time____ Where does this parent live:______________________

Describe child’s relationship with this parent figure:

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Has the child ever been separated from biological father? ____Yes or ___No

If yes, please describe timeline, reasons, and circumstances around separations:

Additional Parents

Mother Figures

(Indicate whether __adoptive __step parent__foster parent ___other_____________)

Mother’s Name_______________________________Age_______Occupation______________________

Years of education________Living or deceased_______If deceased, child’s age at the time:_______

Marital Status_________________________________________________

Nature of the relationship between the child and this mother figure:

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Father Figures

(Indicate whether ____adoptive ____step parent ___foster parent __other___________

Father’s Name______________________________Age_______Occupation______________________

Years of education _____ Living or deceased _______If deceased, child’s when father died _________

Marital Status___________________________________________________

Nature of the relationship between the child and this father figure:

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Other significant adults in your child’s life (e.g. relatives, guardians, very close family friends)

Relationship to Child Describe the relationship, negative and positive aspects

_________________ ______________________________________________________________

_________________ ______________________________________________________________

_________________ ______________________________________________________________

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Child’s Siblings

Name Age Biological, Half, Step Frequency of contact Quality of Relationship

______________ ______ ________________ __________________ ________________________

______________ ______ ________________ __________________ ________________________

______________ ______ ________________ __________________ ________________________

______________ ______ ________________ __________________ ________________________

______________ ______ ______________ __________________ __________________________

______________ ______ ______________ __________________ __________________________

Please describe any emotional, behavioral, learning, ADHD, or health concerns for any of the child’s

siblings:_______________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Describe family life: (e.g., Close, distant, peaceful, turbulent, chaotic, active, calm, involved etc.)

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Please list your immediate family’s strengths and aspects of your family that you enjoy:

______________________________________________________________________________________

______________________________________________________________________________________

Describe activities the family will do together:________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Describe any significant concerns about your child’s parents’ relationship?

______________________________________________________________________________________

______________________________________________________________________________________

How do these concerns impact the child?

______________________________________________________________________________________

______________________________________________________________________________________

Has your child observed or experienced emotional, physical or sexual abuse in the household? Yes or No

If yes, please describe and explain: ________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

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Have you and your spouse ever sought out marriage counseling: Yes or No

If yes, dates___________Counselor______________Reason_____________________________________

Results of counseling____________________________________________________________________

_____________________________________________________________________________________

Please indicate any current concerns you have about your marriage or family:

Describe extended family & friends that provide social support, and the quality of those relationships:

Developmental History Age of Mother at the time of pregnancy:_____ Mother’s health at that time:_______________________

______________________________________________________________________________________

Describe any significant stresses in the family at the time of the child’s birth?_______________________

______________________________________________________________________________________

______________________________________________________________________________________

Did mother experience depression or anxiety during pregnancy or postpartum? _____Yes or_____ No

Did mother have prenatal care? ____Yes or ____No

Did mother drink alcohol or use drugs during pregnancy? ____Yes or ____No

Describe any complications / concerns about the baby’s health during the pregnancy?

Delivery was ____Vaginal ____C-Section Were other instruments used for delivery? Yes or No

Describe any problems during labor & delivery:

Child’s birth weight:__________________ Was APGAR score within normal limits __Yes ___No

Child’s condition after delivery:________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Did the child have colic? ___Yes or ___No

Developmental Milestones:

Child’s age when: ________Sat up ______Crawled ____ Walked _____Spoke first word

_____put 2-3 word phrases together ____toilet trained

Did child have _____excessive drooling _____trouble with tracking visually __avoid eye contact

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Was child reactive to loud noises? __Yes __No Sensitive to the feel of clothing/socks/touch __Yes __ No

As an infant, any concerns with feeding or weight:___________________________________________

____________________________________________________________________________________

As an infant, any concerns with sleeping or napping:_________________________________________

_____________________________________________________________________________________

As a toddler, did your child show a natural interest in exploring and in a variety of toys?

Did your toddler enjoy social interaction?

Did you observe any significant separation anxiety or other fears or worries when your child was a

toddler or preschooler?

Did your child seem to understand and respond appropriately to social cues and the emotional reactions

of others?

Did your child understand humor ____Yes or ___ No

Share his or her experiences with you and others ___Yes or ___No

Acknowledge you when you would return from being away for a time ___Yes or ___No

Was extremely shy ___Yes or ___No Experienced bullying ___Yes or ___No

Make friends easily ___Yes or ___No Indiscriminately friendly to strangers ___Yes or ___No

Plays well with other children ___Yes or ___No Fights with peers ___Yes or ___No

Child is more of a __Leader __Follower __Neither Child ___Has one close friend ___ Many Friend

Gives up own needs for the demands of others ___Yes or ___No Respect authority ___Yes or ___No

Does your child exhibit any conduct problems:

____Lying ____Stealing ___Cheating ___Fire starting ___Fighting ___Destruction

Describe any significant trauma, losses, changes, or difficulties your child experienced during childhood:

Your child’s social activities (e.g., recreation, hobbies, clubs, group associations):

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Does family have a religious or spiritual interest?__Yes __No

If yes, specific religion practiced by the family: _______________________________________________

Does your family attend a local church, parish, synagogue, or masque ____Yes or ___ No

If yes, where do you attend: ________________________________________________________

Is faith or spiritual life important to your child and a resource to him/her? _____________________

Education and Work History

Name of child’s current school_______________________________Teacher_______________________

Current Grade________________ List any tutors or special ed. teachers__________________________

How would you characterize your child’s academic achievement: ___Below Avg ___Avg ___Above Avg

How would you characterize your child’s intellectual ability: ___Below Avg ___Avg ___Above Avg

What kind of feedback do you typically receive from your child’s teachers:

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Has the child ever repeated a grade? ___yes ___No Received special education __Yes __No

Has the child received reading assistance at school (e.g. small group or one on one help)? ___Yes ___No

Has your child received assistance with mathematics? ___Yes ___No

Circle Y below for those characteristics your child often exhibits:

Y N Short attention span Y N Distractibility Y N Impulsivity

Y N Disorganization Y N Peer problems Y N Follower Y N Domineering Y N Dislikes school

Does the child have a ____504 plan _____IEP ____Neither ___Other__________________________

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Does your child require a great deal of assistance with homework at home? ___Yes or ___No

Who helps the child with homework?_____________________________# of hours/night________

Indicate if any your child has any of the following difficulties with school, chores, or work:

☐ Reading ☐ Distractibility ☐ Frequently Bored/Disinterested

☐ Spelling ☐ High absenteeism ☐ Late, sloppy or incomplete tasks

☐ Mathematics ☐ Verbal Expression ☐ Difficulty with peer interactions

☐ Disorganization ☐ Misplacing Items ☐ Trouble with authority figures

☐ Concentration ☐ Remembering Details ☐ Difficulty accepting feedback

☐ Daydreaming ☐ Comprehension ☐ Written Communication

Other:

Please explain any checked items above and any other concerns regarding school or work:

Employment History (If your teen has a job, please complete the section below.)

Current Employment Status:_____full time ____part time

How many hours a week does your child work? __________

Current

Employer:

Position Title:

Length of time in present position: ____________

Describe your child’s attitude toward their present employment situation:

Other types of work and positions your teen has held:

Thank you very much for completing this rather lengthy questionnaire! Please mail this form and the Client information form and the signature pages from the other forms to:

Dr. Langholz, Ph.D. 1930 St. Andrews Ct., NE Suite D Cedar Rapids, IA 52402

protected health information history form...over the last month symptoms have: ___improved...

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