Twin Oaks Counseling
Health Information
Rate your current physical health: _____ Very Good _____ Average _____ Declining
List current physical / mental health problems below:
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Have ou had previous physical health concerns? _____Yes _____No If yes, please list on back.
Have you had previous mental health concerns? _____Yes _____No If yes, please list on back.
Have you ever been hospitalized for a mental health condition? _____Yes _____No
Have you previously sought professional counseling? _____Yes _____No
| Counselor / Psychiatrist |
When? |
How Long? |
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Primary Care Physician:______________________________Phone:______________
What specifically brings you to counseling?
____________________________________________________________________
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What would be different in your life if counseling would be helpful? (goals for yourself)
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List any past or present habits, compulsions or addictions you have:
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How many alcoholic drinks do you normally consume in a typical ____day ____wk ____mo
Do you or have you smoked marijuana? _____Yes _____No When?__________How much?_____________
Other drug use:____________________________________________________________
Briefly describe one or more of your earliest childhood memories:_____________________
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Do you have any recurring dreams or nightmares? _____Yes _____No If yes, please describe:
________________________________________________________________________
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My greatest fears are _______________________________________________________
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please tell us about any past or present abuse in your life (continue on back if necessary):
Physical:_________________________________________________________________
Emotional / Verbal:_________________________________________________________
Sexual:___________________________________________________________________
Rape:____________________________________________________________________
1230 Big Bend Road, Ballwin, Missouri, 63021
636-861-1870
