Name:___ _____ __
__________Date:______ _______
Birthdate: __________ _______ Age:________
_____
Relationship Status:
9 Single 9 Married 9
Divorced 9 Separated 9 Partner
We recognize it is difficult to share personal information. The following confidential assessment is intended to identify
areas in which we may help you overcome challenges and solve problems that could interfere with the improvement and progress
you desire to make.
Section 1: Problems to Solve:
Do you have family or friends close by who you can call to help you when you need it? 9 yes 9 no
On a scale from 1 to 10 (1 being the lowest and 10 being the highest) , Please rate the following questions:
What is your current stress level? 1 2 3 4 5 6 7 8 9 10
What would you say are the causes for the stress in your life? 9 children 9 spouse/relationship 9 money 9 employment
9 health problems/pain 9 social 9 other 9
Where would you rate your individual self esteem?
1 2 3 4 5 6 7 8 9 10
What contributes most to your self esteem? _________
___________________________________________
What would you rate the level of control over your life? 1 2 3 4 5 6 7 8 9 10
What would help you have more control over your life?
How well are you able to complete daily chores/responsibilities? 1 2 3 4 5 6 7 8 9 10
Considering physical, mental and emotional aspects, what keeps you from fulfilling these better? _________
__________________________________________
How would rate your ability to manage your addiction(s)? 1 2 3 4 5 6 7 8 9 10
What are your biggest challenges in this area? ______________________________________________
______________________________________________
Is there any addiction(s) like smoking or something else you would like help to quit? 9 yes 9 no
If yes, what is it?_____________________________ ____________________________________________
Please circle which of the following things help you relax or "renew" yourself:
Nature Music Hobbies Interests Other_______
Hypnosis is a helpful tool for solving various problems, such as addictions like smoking and overeating; chronic pain
like migraines; mental obstacles like self-defeating thoughts; or enhancing performance such as in sports or special skills.
Are there some ways that hypnosis might be useful for you? ______________________________________________
______________________________________________
______________________________________________
To help us better serve you and help you successfully change your life what other challenges would you like us to be aware
of? ___________________________________________
___________________________________________
___________________________________________
Section 2: Drug/Alcohol Use:
1. Have you ever tried to control your use? Y N
2. Has anyone ever criticized your use? Y N
3. Have you ever felt guilty after your use? Y N
4. Have you ever drunk/used first thing in the morning to eliminate a hangover? Y N
5. Have you ever experienced a memory loss when drinking or using drugs? Y N
6. Have you ever missed work/school due to use or hangovers? Y N
7. Have you ever embarrassed yourself due to drug/alcohol use? Y N
8. Have you ever been hospitalized due to or related to your use? Y N
9. Have you ever had any arrests or legal problems related to drug/alcohol use? Y N
10. Has your family expressed concern over your use of chemicals or your behavior? Y N
11. Have you ever lied about the amount or the kind of chemicals that you use? Y N
12. Do you ever hide your chemicals in order to protect your supply? Y N
13. Does it take more to get high than it used to? Y N
14. Are you using more often now than before? Y N
15. Is there anyone that you are related to who has a problem with alcohol or drugs? Y N
16. Have you ever had withdrawal symptoms? Y N
17. Have you ever had seizures during withdrawal? Y N
18. Have you used any drugs/alcohol in the last 48 hours? Y N
19. Do you have any medical problems related to your drinking or drug use? Y N
20. List drugs of choice by preference, including alcohol: __________
__________________________________________________________
21. Do you find yourself checking out or spacing out when you are not drinking or using? Y N
22. Do you use drugs or alcohol in an attempt to block out or numb the pain? Y N
23. Have you ever been prescribed medication to help you manage your mood of anxiety? Y N
24. Have you ever been hospitalized due to a mood or anxiety problem? Y N
Section 3: Medical and Health History:
Do you have or have you ever had any of the following conditions:
|
Headaches/ Migraines |
9 yes 9 no |
Cancer: Type: |
9 yes 9 no |
|
Head Injury |
9 yes 9 no |
Learning disabilities |
9 yes 9 no |
|
Diabetes or Hypoglycemia |
9 yes 9 no |
High Blood Pressure |
9 yes 9 no |
|
Thyroid Problems |
9 yes 9 no |
GI Problems (stomach, reflux or ulcers, etc.) |
9 yes 9 no |
|
Other: |
|
Other:
|
|
Are there any other medical conditions it would be helpful for me to know about? (such as childhood diseases or physical
disabilities)_______________________________________________
___________________________________________________________
Do you experience any of the following symptoms and if so, how long have you experienced them?
Chronic Pain? 9 yes 9 no What areas, General Pain Level (1-10) & For How Long? ______________________ _______________________________________________
Fatigue? 9 yes 9 no How long? ____________________
How Severe? (1-10) ______________________________
Has anyone in your family been treated by a doctor for a mental/emotional illness or condition?
9
yes 9 no If yes, who was
diagnosed and what was the condition? ________________________________________________________
_________________________________________
Have you received counseling before for a mental or emotional problem?
9 yes 9 no
What was it for? ______________________________________________
Do you use over the counter medications for daily aches and pains, stomach problems or to help you sleep?
9 yes 9
no If yes, what is it and what do you use it for? (Does it help?) ______________________
__________________________________________
What medications are you taking currently? (Rate their effectiveness by each one (1-10) ___________
__________________________________________
Would you be wiling to take a medication as part of your mental health treatment?
9 yes 9 no
Do you currently have thoughts like "I wish I was dead" or that you would like to hurt yourself?
9 yes 9 no
If you do, do you know how or do you have a plan how you would do this?
9 yes 9 no
Section 4: Emotional Symptoms:
The following are statements that may or may not describe your current condition. Please read them carefully and mark any
that may apply.
_______I have headaches often enough they interfere with my life.
_______I have frequent stomach pains, burning or nausea.
_______I have frequent diarrhea or constipation.
_______I have muscle aches and pains that can’t be explained.
_______I feel as though I "can’t catch my breath."
_______I often feel sick or tired.
_______I know my nervousness affects my health.
_______I experience strong and sudden fears or panic.
_______I am frightened by certain things or places.
_______I have to double check things again and again.
_______I worry about a lot of things.
_______I suddenly feel restless, like "I have to get out of here."
_______I feel uneasy in crowds and public places.
_______I feel shaky and nervous inside.
_______I think about certain negative things over and over.
_______I don’t do the things I use to enjoy doing.
_______I often have crying spells when I feel sad.
_______My appetite and weight has changed.
_______I find I don’t want to be around other people.
_______I feel hopeless about the future.
_______I feel tired soon after I wake up.
_______I often feel guilty, as though it is my fault.
_______I have difficulty making decisions, thinking or concentrating.
_______I often feel like a failure.
_______I will become mad or angry suddenly if a phrase or situation is mentioned.
_______ I have been known to yell, hit or shove someone.
_______I fume inside and am unable to express my feelings.
_______I fear what my anger may lead me to do someday.
_______I sometimes drive too fast or do other things that are risky in my frustration.
_______I often regret my angry outbursts.
_______I often feel irritated.
_______I have trouble sleeping.
_______I wake up during the night and can’t get back to sleep right away.
_______I toss and turn for most of the night.
_______I often feel tired even when I have slept all night.
_______I wake up early in the morning and can’t get back to sleep.
_______Instead of looking forward to sleep I dread it.
_______I often think about food.
_______I am always on a diet and am trying to lose weight.
_______I often exercise more than one hour a day.
_______I will deny myself food even when I am hungry.
_______I will sometimes "binge" and eat a lot all at once.
_______I will make myself vomit after I have "binged" because I don’t want to gain weight.
_______I will take laxatives or diuretics to lose weight.
_______I prefer to eat alone.
_______I don’t exercise at all.
_______I have trouble getting out of relationships that are not good for me.
_______I usually find my relationships are harmful to me.
_______I often feel lonely and prefer to be alone.
_______I often am not to blame for my problems with others.
_______I often disagree with authority figures like parents, church leaders, or the police.
_______I don’t get along with my family.
_______I have difficulty trusting other people.
_______I have difficulty relating to people who are intimate with me.
_______I have difficulty controlling my sexual behavior.
_______I am often unhappy with my gender.
_______(If married) My marriage is under a lot of strain right now.
_______I often have feelings of being "crazy" and don’t know why.
_______I hear voices and noises that other people do not hear.
_______I often feel as though I am being followed.
_______I feel as though I am losing touch with reality.
_______I sometimes think other people know what I am thinking and are watching me.
_______I feel as though I have special powers and can do things other people can not.
_______During certain times I have a decreased need for sleep.
_______At times I am more talkative than usual or have a pressure to keep talking.
_______Sometimes my thoughts race, it feels like ideas are flying through my mind.
_______At times I am distractible (attention too easily drawn to unimportant things)
_______Periodically I have excessive involvement in pleasurable activities that are risky (buying sprees, foolish investments,
sexual indiscretions)
_______At times I have agitation or restlessness and have to do things (social, work, etc.)
_______It is difficult for me to concentrate and stay on one task.
_______I tend to lose things like my keys, pens, etc.
_______I am easily distracted.
_______I struggled in school or work because I failed to complete assignments or turn them in.
_______I find it difficult to finish projects I begin.
_______I cannot sit still.
_______Sometimes I forget what I am doing or about to do.
(If there is anything else you would like us to understand please write it here and on back)
section 5: Trauma Experiences & Symptoms:
The following section asks about events you may have experienced in life.
Have you personally experienced or have you ever witnessed the following situations?
During Childhood:
There are many difficult experiences we can have in childhood. We can personally experience them and/or witness others
we care for have them. Check any of the following you have been affected by. In the space provided please write anything you
would like us to understand about what happened.
1.___ Death of a loved one. 2. ___ Physical Abuse 3. ___ Sexual Abuse 4. ___ Rape 5. ___ Verbal Abuse
6. ___ Accident (car or other) 7. ___ Parents Fighting 8. ___ Chronic Illness 9. ___ Burns or Serious Injury
10. Alcoholism/Drug Abuse 11. Divorce of Parents 12. Other ________
__________________________________________________________
During Adulthood:
We can also have, of course, difficult experiences when we are adults and we can personally experience them and/or witness
others we care for have them. As above, check any of these you have been affected by. In the space provided please write anything
you would like us to understand about what happened.
1. Death of a loved one. 2. Domestic Violence 3. Rape
4. Loss of a Job 5. Assault
6. ___ Divorce 7. ___ Relationship loss 8. ___ Chronic Illness 9. ___ Alcoholism 10. ___ Drug Addiction 11.
Verbal Abuse 12.
Accident (car or other) 13. Other_________________________
_________________________________________________________
Please mark if you currently experience any of these symptoms:
_______ Nightmares or dreams that cause you to feel frightened.
_______Flashbacks (sudden memories, feelings or images)
_______Unpleasant feelings associated with people or places that are so strong that you avoid them.
_______Feeling like you are reliving a "bad memory"
_______Suddenly feeling extreme agitation or despair and not knowing where its from
_______Feeling numb, not having any feelings.
_______A loss of memory for some events that are significant, i.e, a wedding or graduation
_______Unable to account for blocks of time during the day.
_______Discovering you did things you don’t remember doing.
_______Discovering yourself in a place and don’t know how you got there.
_______Feeling like you are two or more different people because you behave and act differently compared to what you
might think is "normal"
