Personal Information

Name: Laura Summers

DOB: 12/21/84

Age: 34

Gender: Female

Address: 321 Main St. Pittsburgh, PA 15228

Home Phone: N/A

Can a message be left? N/A

Cell Phone: 512-7723

Can a message be left? Yes

Emergency Contact: Ben Summers, Spouse 512-4487

Marital Status: Separated

Referred by (if any)? Referred to treatment by my primary care doctor, Dr. Smith.

Current Employment Status: Part time as a dog groomer.

History

Have you previously received any type of behavioral health services (psychotherapy, psychiatric services, etc)? Yes, I was hospitalized when I was 17 for a suicide attempt and followed up with counseling services at a New Day counseling practice. Attended counseling for about 2 months.

Are you currently taking any prescription medication: Yes, thyroid medication. I take Levothyroxine 25mcg 1 x day.

Have you ever been prescribed any psychiatric medication? Yes, I was given medication after my hospitalization, at discharge- an antidepressant? Did not take it.

General Physical and Mental Health Information

1. How would you rate your current physical health? (Poor, Fair, Good, Very Good?) At the moment, fair. I am tired a lot and have low energy.
2. How would you rate your current sleep habits? (Poor, Fair, Good, Very Good?) Poor. I tend to sleep 10-11 hours a day. Have trouble staying asleep and wake up a lot.
3. Do you exercise? If so, how many days a week? No.
4. How is your appetite? Are you experiencing any eating problems? I have had poor appetite the past several months. Usually eat one meal a day.
5. Are you currently feeling down, depressed or hopeless? Down yes. Not hopeless. If so, for how long? Several months.
6. Are you currently experiencing any anxiety, panic attacks or have any phobias? No
7. Are you currently experiencing any chronic pain? Lower back pain
8. How often do you drink alcohol? Several times a week How many alcoholic beverages do you have on a day when you are drinking? 3-4 glasses of wine
9. Do you engage in recreational drug use? No If so, how often? N/A
10. Have you had any significant life changes or life stressors recently? Yes. I am recently separated from my husband of 4 years. He wants me to seek treatment for depression. I also have family stressors as my mother is currently receiving treatment for breast cancer and myself and my older sister are her main caregivers/support system.

Family Mental Health History

Please list in the section below if any of your family members have a history of the following behavioral health problems. Please indicate who the family member is in relation to you (father, grandmother, sibling, cousin).

	Yes/No:	Family Member:
Alcoholism	Yes	Father
Drug Abuse	No
Depression	Yes	Father, Maternal Grandmother
Anxiety	Yes	Mother, Sister
Panic Attacks	No
Obsessive Compulsive Disorder	No
Post Traumatic Stress Disorder	No
Bipolar Disorder	No
Eating Disorder	No
Schizophrenia	No
Suicide Attempts	Yes	Myself
Psychiatric Hospitalization	Yes	Myself

How do I fill this out properly? With the information given above.

Clinician Name: (Your name here)

Treatment Modality: (How often will you be seeing this patient?)

Therapeutic Approach: (Examples: Person-Centered, Motivational Interviewing, Cognitive Behavioral)

Client(s) Goal 1: Lauren will decrease depression symptoms.

Objective 1: What are small actions Lauren can take to reach this goal?

Objective 2:

Objective 3:

Client(s) Goal 2: Lauren will learn positive coping skills to deal with life stressors.

Objective 1: What are small actions Lauren can take to reach this goal?

Objective 2:

Objective 3:

Current Client Strengths, Assets, Tools, and/or Abilities:

Progress Monitoring:

Example: Patient will be administered the PHQ9 periodically to measure depression symptoms, ongoing.

Endorsement of the Client Name and Clinician Name below indicates verbal consent and agreement to the treatment plan outlined above.