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Processing Form
Adult History
Client first name
Client last name
Client email
Date of birth
Gender
Select...
Male
Female
Who referred you to Pediatric Connections?
Why were you referred?
Please explain why you're seeking services (i.e. Childhood trauma, recent car accident, debilitating anxiety, etc.)
Family Information
Client lives with
Please list all persons living in the home with names and relationship to client
Client Occupation
Medical History
Describe Medical History
Include diagnosis and explain any significant factors resulting in the need to seek further care
Medications
Emotional
Emotional health is expressing your emotions in a positive, non-destructive way.
Please rate each on a scale from 1-10
Calm
Select...
1 - Calm
2
3
4
5
6
7
8
9
10 - Anger
Happy
Select...
1 - Happy
2
3
4
5
6
7
8
9
10 - Sad
Safe
Select...
1 - Safe
2
3
4
5
6
7
8
9
10 - Fearful
Hopeful
Select...
1 - Hopeful
2
3
4
5
6
7
8
9
10 - Hopeless
Peaceful
Select...
1 - Peaceful
2
3
4
5
6
7
8
9
10 - Frustrated
Comments
Please specify recent environmental stressors (i.e. Increased work demands, challenging living situation, etc.)
Physical
Physical health refers to the way that your body is functioning. This includes eating habits, sleep patterns, getting regular exercise, and being at your recommended body weight. Physical health could also be impacted by pain, sickness, disease, medications, drugs, and/or alcohol.
Please rate each on a scale from 1-10
Appetite
Select...
1 - Healthy
2
3
4
5
6
7
8
9
10 - Irregular
Sleep quality
Select...
1 - Restful
2
3
4
5
6
7
8
9
10 - Restless
Sleep quantity
Select...
1 - Ideal
2
3
4
5
6
7
8
9
10 - Irregular
Pain
Select...
1 - No Discomfort
2
3
4
5
6
7
8
9
10 - Extreme Pain
Health
Select...
1 - Healthy
2
3
4
5
6
7
8
9
10 - Unhealthy
Comments
Please include any medication changes, new illnesses, or anything related to physical health
Social
Social Health is the quality of your relationships with friends, family, teachers and others you are in contact with.
Please rate each on a scale from 1-10
Relationship with significant other
Select...
1 - Thriving
2
3
4
5
6
7
8
9
10 - Stressful
Relationship with children
Select...
1 - Thriving
2
3
4
5
6
7
8
9
10 - Stressful
Relationship with peers
Select...
1 - Thriving
2
3
4
5
6
7
8
9
10 - Stressful
Relationship with colleagues
Select...
1 - Thriving
2
3
4
5
6
7
8
9
10 - Stressful
Comments
Please include your typical response to stressors
Intellectual/Mental Health
Mental Health is the ability to think clearly and critically, problem solving abilities, learning abilities, and knowledge learned throughout life. Example: Reading books, taking classes, learning a new language or trade, or working on an art project.
Please rate each on a scale from 1-10
Clarity of thought
Select...
1 - Clear
2
3
4
5
6
7
8
9
10 - Brain Fog
Clarity of speech
Select...
1 - I make total sense
2
3
4
5
6
7
8
9
10 - I make no sense
Ability to focus
Select...
1 - Laser Focus
2
3
4
5
6
7
8
9
10 - Distracted
Completion of task
Select...
1 - Completed all tasks
2
3
4
5
6
7
8
9
10 - Completed no tasks
Comments
Please include your typical response to stressors
Daily Functioning
How does stress effect your daily functioning? Are you able to complete daily tasks? (Includes taking care of personal needs, completing daily routine of eating)
Please rate each on a scale from 1-10
Daily tasks
Select...
1 - Completes all daily tasks with ease
2
3
4
5
6
7
8
9
10 - Unable to do any daily tasks
Comments
Please include your typical response to stressors
Stress Resiliency
As typical stressful events occur in daily life, are you able to address and move forward?
Please rate each on a scale from 1-10
Response to stress
Select...
1 - Able to address and move on
2
3
4
5
6
7
8
9
10 - Stressors derail
Comments
Please include your typical response to stressors
Goals
It is important that we partner in establishing goals for therapeutic intervention. Please list the top priorities we can address first:
Goal #1
Goal #2
Goal #3
Goal #4
Any other comments/concerns not addressed above?
Submit