New Client Screening Form Page 3
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3Choices Counseling & Resource Center, PA
SCREENING FORM
LIFE HISTORY (cont’d)
Problems (that currently concern or worry you)
Relationships with:
spouse
parents
children
siblings
friends
extended‐family
co‐workers teachers
Other problems:
infidelity
substance use (alcohol/street drugs/prescription drugs)
eating issues (binging/purging/excessive dieting)
depression anger anxiety stress grief
fear loneliness
school/academic problems (low grades, test anxiety, peer problems)
other: _________________________________
Current Symptoms (as they apply to you today)
Mood: sad elated
hopeless
low energy poor concentration angry
Anxiety: worry
panic fearfulness compulsive
Thought: depression hallucinations
obsessive
distractible
Behavior: aggressive truant/runaway disorganized
compulsive
Sleep: (describe) ____________________________________________________
Appetite: (describe) ________________________________________________
Other symptoms not listed: ______________________________________
Intense Emotional Distress: Explain below anything that is currently happening or has
happened in the last two weeks.
Suicidal thoughts/plans/attempts: _________________________________________________________
Homicidal thoughts/plans/attempts: ______________________________________________________
Desire to cause pain to self or others: ______________________________________________________
In fear for own life or own safety: __________________________________________________________
Too depressed to care for self or family: ___________________________________________________
Therapist use only: reviewed in session – initial here _________ date/time ______________
Briefly state why you are coming to counseling:
State three goals you hope to accomplish:
1. _______________________________________________________________________________
2. _______________________________________________________________________________
3. _______________________________________________________________________________
THE CONTENTS OF THIS SCREENING FORM ARE CONFIDENTIAL AND WILL NOT BE
RELEASED WITHOUT WRITTEN PERMISSION FROM CLIENT/PARENT/GUARDIAN.
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Revised 2/2010
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Parent category: Medical