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Adult Informed Consent

informed_consent_adult_6_17_20.pdf
File Size:	416 kb
File Type:	pdf

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Adolescent Informed Consent

chc_adolescent_informed_consent__june_2020.pdf
File Size:	704 kb
File Type:	pdf

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* Indicates required field

Name *

First

Last

Email *

Phone *

Address *

City *

State *

Zip *

County *

How long at this address? *

Relationship Status *

Education completed *

Employer *

Occupation *

How long at company? *

Name of person responsible for payment *

Address (if different from above) *

Phone No. *

Partner/Spouse *

Partner/Spouse age *

Education *

Partner employer *

Partner phone *

Partner/Spouse address (if different) *

Military service *

Children/HH member name (1) *

Child/HH age (1) *

Relationship (1) *

Children/HH member name (2) *

Child/HH age (2) *

Relationship (2) *

Children/HH member name (3) *

Child/HH age (3) *

Relationship (3) *

Children/HH member name (4) *

Child/HH age (4) *

Relationship (4) *

Nearest relative (not living with you) *

Relationship to relative *

Address *

City, state, zip *

Emergency contact *

Relationship to emergency contact *

Emergency contact phone *

Date of last physical *

List all medications currently taking (including over-the-counter) *

Any psychiatric hospitalizations? *

Reason *

Where *

Length of stay *

Current or past physical problems? *

Do you exercise regularly? *

How are you sleeping? *

Average no. of hrs a night *

Sleeping routine *

Appetite? *

Do you experience anxiety or stress often? *

How long has this been happening? *

Do you experience chronic pain? *

How long have you had the pain? *

Alcohol consumption over 2x a week? *

Do you use any unprescribed drugs? *

Any significant life changes in the last 3 years? *

Any trauma that you are aware of? *

How important is religion/spirituality in your daily life? *

Have you received counseling in the past? *

How long ago did you receive counseling? *

Reason for seeing a therapist before? *

Why are you seeking counseling now? *

What do you consider your strengths and goals? *

What are your weaknesses and biggest struggles? *

Below are common problems. Read carefully and choose the number that best describes how much that problem is a concern to you. *

1 = Not at all *

2 = Mildly *

3 = Moderately *

4 = Very Much *

5 = Extremely *

Feeling low in energy or slowed down. *

Dissatisfied with my spiritual life. *

Repeated, unwanted thoughts difficult to dismiss. *

Loss of control, or fear of losing control of my temper. *

Not satisfied with my weight. *

Nervousness or shakiness inside. *

Troubled by sexual thoughts or behavior. *

Drink when troubled or under pressure. *

Unusual fears that most people don’t have. *

Thoughts of ending my life. *

Sleep that is restless or disturbed. *

Problems with police or legal matters. *

Feel withdrawn and/or isolated. *

Loss/absence of sexual desire or pleasure. *

Other people being aware of my private thoughts. *

Feeling hopeless about the future. *

Problems with my eating. *

Spells of terror or panic. *

Feeling shy or uneasy with opposite sex/same sex. *

Drinking/emotional problems in my family. *

Feeling that I am watched or talked about by others. *

Things about my life are too painful to talk about. *

Difficulty feeling close to another person. *

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