Fillable CFC Intake Form V3

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CFC Intake Form V3

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The CFC Intake Form V3 form is 3 pages long and contains:

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  • 200 check-boxes
  • 43 other fields

Country of origin: US
File type: PDF

U.S.A. forms for University of Nebraska, Lincoln

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For staff use only:
Client Name: ______________________________________ Client Number: _______________________________
BIOPSYCHOSOCIAL ASSESSMENT – ADULT
Today’s Date _______________
Name _________________________________________________
Date of Birth _______________
Email Address ___________________________________________
Preferred Language ______________________________________
Do you need an Interpreter?
□ Yes □ No
Please complete this form in its entirety. If you wish not to disclose personal information, please check “No Answer” (NA).
PRESENTING PROBLEM
1. Please describe what brings you in today? _______________________________________________________
2. How long have you been experiencing this problem? □Less than 30 day □1-6 months □1-5 years □5+ years
3. Rate the intensity of the problem 1 to 5 (1 being mild and 5 being severe): □1 □2 □3 □4 □5
4. How is the problem interfering with your day-to-day functioning? ____________________________________
5. What are your current goals for therapy? If treatment were to be successful, what would be different?
__________________________________________________________________________________________
__________________________________________________________________________________________
6.
Are you currently or in the last 30 days experienced any of the following symptoms? (check all that apply)
□ Sadness □Hopeless/Helpless
□ Sleep Too
Much
□ Fatigue/No
Energy
□ Poor Memory
□ No Motivation □ Lack of Interest
□ Thoughts of
Dying
□ Guilt
□ Feel
Worthless
□ Not Hungry
□ Prefer Being
Alone
□ Irritable/
Angry
□ Can’t Sleep
□ Too Much
Energy
□ No Need for Sleep □ Talk Too Fast □ Impulsive
□ Can’t
Concentrate
□ Restless/Can’t
Sit Still
□ Suspicious □ Hearing Things □ Seeing Things
□ Have Special
Powers
□ People
Watching Me
□ People Out to Get
Me
□ Feeling Nervous □ Fearful □ Panic Attacks
□ Can’t be in
Crowds
□ Easily Startled □ Avoidance
□ Re-occurring
Nightmares
9.
Are you pregnant now?......................................................................................................
Yes No NA
7. □ □ □
10.
If yes, when are you due? (day/month/year) __________________________________
11.Are you at risk for HIV/AIDS/Sexually Transmitted Diseases (unsafe sex, using needles?)
11. □
□ □
12.
Please list allergies to medications or food: ___________________________________
__________________________________________________________________________
13. Has your physical health kept you from participating in activities?...................................
13. □
□ □
Do you now or have you ever contemplated suicide?.......................................................
8.
Are you a survivor of trauma?............................................................................................
8. □ □ □
7.
9. □ □
□
For staff use only:
Client Name: ______________________________________ Client Number: _______________________________
TOBACCO
Yes No NA
1. Have you ever used any forms of tobacco (cigarettes, snuff, etc.)? IF NO SKIP TO NEXT
SECTION………………………………………………………………………………………………………………………………
1. □ □ □
2. Are you a former tobacco user?...........................................................................................
2. □ □ □
□
Cigarettes □ Cigars □ Snuff □ Chewing Tobacco □ Snuff □ Other
Cigarettes____ Cigars____ Snuff____ Chewing Tobacco____ Snuff____
5. Have you been involved in a program to help you quit using tobacco in the past 30
days?........................................................................................................................................
5. □ □ □
6. If so, which self-help group was used?_________________________________________
SUBSTANCE USE/ADDICTION PRESENT
Yes No NA
1. Would you or someone you know say you are having a problem with alcohol?......…………
1. □ □ □
2. Would you or someone you know say you are having problems with pills or illegal
drugs?.......................................................................................................................................
2. □ □ □
3. Would you or someone you know say you are having problems with other addictions, ie.
gambling, pornography or shopping?......................................................................................
3. □ □ □
4. Have you ever been to a self-help group?...........................................................................
4. □ □ □
SUBSTANCE USE/ADDICTION PAST
Yes No NA
1. Would you or someone you know say you had a problem with alcohol?......……………………
1. □ □ □
2. Would you or someone you know say you had problems with pills or illegal drugs?..........
2. □ □ □
3. Would you or someone you know say you had problems with other addictions, ie.
gambling, pornography or shopping?......................................................................................
3. □ □ □
4. Is there a family history of addiction in your family?...........................................................
4. □ □ □
5. If yes, please describe: _____________________________________________________
PERSONAL, FAMILY AND RELATIONSHIPS
1. Who is in your family? (parents, brothers, sisters, children, etc.)____________________
__________________________________________________________________________
Yes No NA
2. Has there been any significant person or family member enter or leave your life in the
last 90 days?.............................................................................................................................
2. □ □ □
Good Fair Poor Close Stressful Distant Other
3. How are the relationships in your family?................................
□ □ □ □ □ □ □
4. How are the relationships in your support system (friends,
extended family, et.?)……………………………………………………………….
□ □ □ □ □ □ □
Conflict Abuse Stress Loss Other
5. Are there any problems in your family now? (check all that apply)…………..
□ □ □ □ □
6. Were there any problems with your family in the past? (check all that
apply)…………………………………………………………………………………………………………...
□ □ □ □ □
7. Are there any problems in your support system now? (check all that
apply)……………………………………………………………………………………………………………
□ □ □ □ □
8. Were there any problems with your support system in the past? (check
all that apply)……………………………………………………………………………………………….
□ □ □ □ □
9. What is your marital status now? □Single □Married □Living as Married □Divorced
□Widowed □Never Married
For staff use only:
Client Name: ______________________________________ Client Number: _______________________________
Yes No NA
10. Have you ever had problems with marriage/relationships?..............................................
10. □ □ □
11. If yes, please check why: □Stress □Conflict □Loss □Divorced/Separation
□Trust Issues □Other_______________________________
12. Do you have any close friends?..........................................................................................
12. □ □ □
13. Do you have problems with friendships?...........................................................................
13. □ □ □
14. Do you get along well with others (neighbors, co-workers, etc.)?.....................................
14. □ □ □
15. What do you like to do for fun? _____________________________________________
EDUCATION
Yes No NA
1. What is the highest grad you completed in school? (please check)
□No Education □K-5 □6-8 □9-12 □GED □College Degree □Masters Degree
2. Would you describe your school experience as positive or negative?________________
3. Are you currently in school or a training program?..............................................................
3. □ □ □
LEGAL
Yes No NA
1. Have you ever been arrested? IF NO SKIP TO NEXT SECTION………………………………………….
1. □ □ □
2. In the past month?...............................................................................................................
2. □ □ □
3. If yes, how many times? ____________________________________________________
4. In the past year?...................................................................................................................
4. □ □ □
5. If yes, how many times? ____________________________________________________
6. If yes, what were you arrested for? ___________________________________________
7. What was the name of your attorney? ________________________________________
8. Were you ever sentenced for a crime?…………………………………………………………………………….
8. □ □ □
9. If yes, number of prison sentences served? ____________________________________
10. What year(s) did this occur? _______________________________________________
11. Are you currently or have you ever been on probation or parole?....................................
11. □ □ □
12. If yes, what is the name of your attorney or probation officer? ____________________
WORK Yes No NA
1. What is your work history like? □Good □Poor □Sporadic □Other
2. How long do you normally keep a job? □Weeks □Months □Years
3. Are you retired?....................................................................................................................
3. □ □ □
4. If yes, what kind of work do you do/did you do in the past? _______________________
5. Have you ever served in the military?..................................................................................
5. □ □ □
6. If yes, are you: □Active □Retired □Other
MEDICAL
Yes
□
No
1.
Current Primary Care Physician: __________________________________Phone_________________
□
2.
Past and Current Medical/Surgical Problems: _____________________________________________
3.
Past and Current Medications and Dosages: ______________________________________________
4.
Have you seen a Mental Health Professional Before?
5.
If yes, Name, When, and Reason for Changing: ____________________________________________
6.
Current Psychiatrist/APRN, if applicable:_________________________________________________
7.
_______________________________________________________________
___________________
Is there anything else you would like me to know about you?_______________________________
_______________________________________________________________
___________________
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CFC Intake Form V3

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Completed 23 June 2020

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