Patient name Date

BIOPSYCHOSOCIAL HISTORY

CURRENT SYMPTOM CHECKLIST (Rate intensity of symptoms currently present)

None Mild Moderate Severe None Mild Moderate Severe
Depressed mood Binging/purging
Appetite disturbance Guilt
Sleep disturbance Elevated mood
Paranoia Fatigue/low energy
Self-mutilation Hyperactivity
Poor concentration Mood swings
Irritability Emotionality
Anxiety Panic attacks
Obsessions/compulsions Physical trauma victim
Anorexia Paranoia
Hallucinations Aggressive behaviors
Conduct problems Oppositional behavior
Sexual dysfunction Grief
Hopelessness Substance abuse
Social isolation Worthlessness
Emotional trauma victim Sexual trauma victim

EMOTIONAL/PSYCHIATRIC HISTORY
Prior outpatient psychotherapy? Prior inpatient psychotherapy?
No Yes If yes, on occasions. No Yes If yes, on occasions.

FAMILY HISTORY
Present during childhood: Parent’s current marital status:
Present Present Not married to each other
entire part of present separated for years
childhood childhood at all divorced for years
Mother mother remarried times
Father father remarried times
Stepmother mother involved with someone
Stepfather father involved with someone
Brother(s) mother deceased for years
Sister(s) father deceased for years

Describe childhood family experiences:

outstanding home environment
normal home environment
chaotic home environment
witnessed physical/verbal/sexual abuse toward
others experienced physical/verbal/sexual abuse from
others
 Patient name Date

IMMEDIATE FAMILY
Marital Status: Intimate Relationship: List all persons living in client’s household:
[ ] single, never married [ ] never been in a serious relationship Name Age Relationship to client
[ ] engaged months [ ] not currently in relationship
[ ] married for years [ ] currently in serious relationship
[ ] divorced for years
[ ] separated for years
[ ] divorce in process Relationship satisfaction:
[ ] widowed for years [ ] very satisfied with relationship
[ ] live-in for years [ ] satisfied with relationship List children not living in the same household as client:
[ ] prior marriages (self) [ ] somewhat satisfied
[ ] prior marriages (partner) [ ] dissatisfied with relationship

MEDICAL HISTORY
(check all that apply for client)

Describe current physical health: [ ] Good [ ] Fair [ ] Poor Is there a history of any of the following in the family?
List name of primary care physician: [ ] tuberculosis [ ] heart disease
Name Phone [ ] birth defects [ ] high blood
pressure List name of psychiatrist (if any): [ ] emotional
problems [ ] alcoholism
Name Phone [ ] behavior problems [ ] diabetes
[ ] thyroid problems [ ] drug abuse
[ ] cancer [ ] Alzheimer’s
disease/Dementia List any know allergies: [ ] mental retardation [ ] stroke
[ ] other chronic or serious health problems

Check any of the following problems you have or have had:

Asthma [ ] Bladder problems [ ] Cancer [ ] Chronic pain [ ] Diabetes

[ ] Epilepsy [ ] Gastrointestinal problems [ ] Glaucoma [ ] Headaches [ ] Heart disease
[ ] High blood pressure [ ] Infections [ ] Kidney Disease [ ] Liver disease [ ] Neurological problems
[ ] Prostrate problems [ ] Thyroid disease [ ] Menopause [ ] Premenstrual syndrome [ ] Postpartum
depression

List any medications you are currently taking

(Give dosage and reason)

Medication Dosage Reason

3
Patient name Date

SUBSTANCE USE HISTORY

Substances used Currently using?

(complete all that apply) (Yes/No) First use age Last use age Frequency Amount
[ ] alcohol
[ ] amphetamines/speed
[ ] barbiturates/owners
[ ] caffeine
[ ] cocaine
[ ] crack cocaine
[ ] hallucinogens (e.g., LSD)
[ ] inhalants (e.g., glue, gas)
[ ] marijuana or hashish
[ ] nicotine/cigarettes
[ ] PCP
[ ] prescription
[ ] other

Family alcohol/drug abuse history: Substance use status: Treatment history:

[ ] father [ ] stepparent/live-in [ ] no history of abuse [ ] outpatient (age)(s)
[ ] mother [ ] uncle(s) aunt(s) [ ] active abuse [ ] inpatient (age)(s)
[ ] grandparents(s) [ ] spouse/significant other [ ] early partial remission [ ] 12-step program (age)(s)
[ ] sibling(s) [ ] children [ ] sustained full remission [ ] stopped on my own (age)(s)
[ ] other [ ] sustained partial remission

SOCIO ECONOMIC HISTORY (check all that apply for client)

Living situation: Social support system: Sexual history:
[ ] housing adequate [ ] supportive network [ ] heterosexual orientation [ ] currently sexually dissatisfied
[ ] homeless [ ] few friends [ ] homosexual orientation [ ] age first sex experience
[ ] housing overcrowded [ ] substance-use-friends [ ] bisexual orientation [ ] age first pregnancy/fatherhood
[ ] dependent on other [ ] no friends [ ] currently sexually active [ ] history of promiscuity age to
for housing [ ] distant from family

Employment: Legal history: Financial Situation:

[ ] employed [ ] no legal problems [ ] no current financial problems
[ ] unemployed [ ] now on parole/probation [ ] large indebtedness
[ ] retired [ ] arrest(s) not substance-related [ ] poverty or below-poverty income
[ ] coworker conflicts [ ] arrest(s) substance-related [ ] impulsive spending
[ ] supervisor conflicts [ ] court ordered this treatment [ ] relationship conflict over finances
[ ] unstable work history [ ] jail/prison times
[ ] disabled
[ ] student

4
 Patient name Date

CULTURAL/SPIRITUAL/RECREATIONAL HISTORY
Cultural identity (e.g., ethnicity, religion):
Currently active in community/recreational activities? Yes [ ] No [
] Formally active in community/recreational activities? Yes [ ] No [
] Currently participate in hobbies? Yes [ ] No [ ]
Currently participate in spiritual activities? Yes [ ] No [ ]

Check any of the following words which apply to you:

Horrible thoughts worthless useless a nobody life is empty inadequate stupid

Can’t do anything right incompetent naïve guilty evil morally wrong considerate
Hostile full of hate anxious agitated cowardly unassertive panicky
Aggressive ugly deformed unattractive repulsive depressed lonely
Unloved misunderstood bored restless confused unconfident in conflict
Full of regrets worthwhile sympathetic intelligent attractive confident

I agree to undertake therapy with

Print Client’s name:
Client Signature: Date:
Parent/Guardian Signature (if applicable): Date:
Therapist’s Signature: Date:
NAME: DATE:

DRUG USE QUESTIONNAIRE {DAST - 20)

The following questions concern information about your potential

involvement with drugs not including alcoholic beverages during the

past 12 months.

Carefully read each statement and decide if your answer is "Yes" or

"No". Then, circle the appropriate response beside the question. In

the statements "drug abuse" refers to (1) the use of prescribed or

over the counter drugs in excess of the directions and (2) any non-

medical use of drugs. The various classes of drugs may include:

cannabis (e.g. marijuana, hash), solvents, tranquillizers (e.g.

Valium), barbiturates, cocaine, stimulants (e.g. speed), hallucinogens

(e.g. LSD) or narcotics (e.g. heroin). Remember that the questions

do not include alcoholic beverages.

Please answer every question. If you have difficulty with a

statement, then choose the response that is mostly right.

© Copyright 1982 by Harvey A. Skinner, PhD and the Centre for Addiction and
Mental Health, Toronto, Canada. You may reproduce this instrument for non-
commercial use (clinical, research, training purposes) as long as you credit the
author Harvey A. Skinner, Department of Public Health Sciences, University of
Toronto.
These questions refer to the past 12 months. Shade Your
Respon
1. Have you used drugs other than those required for medical se
Yes No
reasons?

2. Have you abused prescription drugs? Yes No

3. Do you abuse more than one drug at a time? Yes No

4. Can you get through the week without using drugs? Yes No

5. Are you always able to stop using drugs when you want to? Yes No

6. Have you had "blackouts" or "flashbacks" as a result or drug Yes No

use?
Yes No
7. Do you every feel bad or guilty about your drug use?
Yes No
8. Does your spouse (or parents} ever complain
about your involvement with drugs?
Yes No
9. Has drug abuse created problems between you and your
spouse or your parents?
Yes No
10. Have you lost friends because of your use of drugs?

11. Have you neglected your family because of your use of Yes No
drugs?
Yes No
12. Have you been in trouble at work {or school} because of
drug abuse? Yes No

13. Have you lost your job / missed assignments because of Yes No
drug abuse?
Yes No
14.Have you gotten into fights when under the influence of
drugs?
Yes No
15. Have you engaged in illegal activities in order to obtain
drugs? Yes No

16. Have you been arrested for possession of illegal drugs?

Yes No
17.Have you ever experienced withdrawal symptoms (felt
sick) when you stopped taking drugs?
Yes No
18.Have you had medical problems as a result of your drug use
{e.g. memory loss, hepatitis, convulsions, bleeding, etc.)? Yes No

19. Have you gone to anyone for help for drug problem?

20.Have you been involved in a treatment program

specifically related to drug use?

© Copyright 1982 by Harvey A. Skinner, PhD and the Centre for Addiction and
Mental Health, Toronto, Canada. You may reproduce this instrument for non-
commercial use {clinical, research, training purposes) as long as you credit the
author Harvey A. Skinner, Department of Public Health Sciences, University of
Toronto.
DAST-20:
Number Yes No Client Score
1 1 0
2 1 0
3 1 0
4 0 1
5 0 1
6 1 0
7 1 0
8 1 0
9 1 0
10 1 0
11 1 0
12 1 0
13 1 0
14 1 0
15 1 0
16 1 0
17 1 0
18 1 0
19 1 0
20 1 0
TOTAL
Patient Name: Date:

The Michigan Alcoholism Screening Test (MAST)

Please circle either Yes or No for each item as it applies to you.

1. Do you feel you are a normal drinker? (By normal we mean you
drink less than or as much as most other people.) Yes No
2. Have you ever awakened the morning after some drinking the
night before and found that you could not remember a part of Yes No
the evening?
3. Does your wife, husband, a parent , or other near relative ever
worry or complain about your drinking? Yes No
4. Can you stop drinking without a struggle after one or two drinks? Yes No

5. Do you ever feel guilty about your drinking? Yes No

6. Do friends or relatives think you are a normal drinker? Yes No
7. Are you able to stop drinking when you want to? Yes No
8. Have you ever attended a meeting of Alcoholics Anonymous (AA)? Yes No
9. Have you gotten into physical fights when drinking? Yes No
10. Has your drinking ever created problems between you and your Yes No
wife, husband, a parent, or other relative?
11. Has your wife, husband (or other family members) ever gone to Yes No
anyone for help about your drinking?
12. Have you ever lost friends because of drinking? Yes No
13. Have you ever gotten into trouble at work or school because of Yes No
drinking?
14. Have you ever lost a job because of drinking? Yes No
15. Have you ever neglected your obligations, your family or your
work for two or more days in a row because you were drinking? Yes No
16. Do you drink before noon fairly often? Yes No
17. Have you ever been told you have liver trouble? Cirrhosis? Yes No
18. After heavy drinking have you ever had Delirium Tremens Yes No
(D.T.s) or severe shaking, or heard voices or seen things that
really were not there?
19. Have you ever gone to anyone for help about your drinking? Yes No
20. Have you ever been in a hospital because of drinking? Yes No
21. Have you ever been a patient in a psychiatric hospital or on a Yes No
psychiatric ward of a general hospital where drinking was part of
the problem that resulted in hospitalization?
22. Have you ever been seen at a psychiatric or mental health clinic,
or gone to any doctor, social worker, or clergyman for help with
an emotional problem, where drinking was part of the problem? Yes No
23. Have you ever been arrested for drunk driving, driving while
intoxicated, or driving under the influence of alcoholic Yes No
beverages?
(If YES, how many times? )
24. Have you ever been arrested, or taken into custody even for a
few hours, because of other drunk behavior? Yes No
If YES, how many times? )
 THE BURNS ANXIETY INVENTORY

INSTRUCTIONS: The following is a list of symptoms that

2-MODERATELY
people sometimes have. Put a check ( ) in the space to the

1-SOMEWHAT
0-NOT AT ALL
right that bests describes how much that symptom or
problem has bothered you during this past week.

3-A LOT
SYMPTOM LIST

CATEGORY I: ANXIOUS FEELINGS

1. Anxiety, Nervousness, Worry, and Fear

2. Feeling that things around you are strange, unreal or

foggy
3. Feeling detached from all or part of your body

4. Sudden unexpected panic spells

5. Apprehension or a sense of impending doom

6. Feeling tense, stressed, “uptight,” or on edge

CATEGORY II: ANXIOUS THOUGHTS

7. Difficulty concentrating

8. Racing thoughts or your mind jumps from one thing to

the next.
9. Frightening fantasies or daydreams

10. Feeling that you're on the verge of losing control

11. Fears of cracking up or going crazy

12. Fears of fainting or passing out

13. Fears of physical illness or heart attacks or dying

14. Concerns about looking foolish or inadequate in front of

others
15. Fears of being alone, isolated, or abandoned

16. Fears of criticism or disapproval

17. Fears that something terrible is about to happen

CAEGORY III: PHYSICAL SYMPTOMS

18. Skipping or racing or pounding of the heart
(palpitations)
19. Pain, pressure, or tightness in the chest

20. Tingling or numbness in the toes or fingers

21. Butterflies or discomfort in the stomach

22. Constipation or diarrhea

23. Restlessness or jumpiness

24. Tight, tense muscles

25. Sweating not brought on by heat

26. A lump in the throat

27. Trembling or shaking

28. Rubbery or “jelly” legs

29. Feeling dizzy, lightheaded, or off balance

30. Choking or smothering sensations or difficulty

breathing
31. Headaches or pains in the neck or back

32. Hot flashes or cold chills

33. Feeling tired, weak, or easily exhausted

Add up your total score for the 33 symptoms and record

it here.

DATE:

TOTAL SCORE DEGREE OF YOUR SCORE

ANXIETY
0-4 Minimal or No Anxiety
5-10 Borderline Anxiety

11-20 Mild Anxiety

21-30 Moderate Anxiety

31-50 Severe Anxiety

51-99 Extreme Anxiety or

Panic
 HOW TO OVERCOME FEARS, PHOBIAS, AND PANIC ATTACKS

1. THE Do an experiment to test your belief that you're “cracking

EXPERIMENTAL up” or “having a heart attack” or “losing control.”
METHOD
2. PARADOXIAL Exaggerate your fears instead of running away from them.
TECHNIQUES If you have the fear of cracking up or having a stroke, you
try your hardest to crack up or have a stroke.
3. SHAME- Purposely do something silly in public, in order to overcome
ATTACKING your fear of appearing foolish.
EXERCISES
4. CONFRONT Expose yourself to whatever you're afraid of instead of
YOUR FEARS running away and letting your fears cripple you. There are
three ways of doing this:
Sudden exposure Allow yourself to experience all your symptoms, no matter
or “flooding” how bad they get. You endure your fears until they run their
course.
Gradual exposure You gradually expose yourself to whatever you're afraid of
(like being away from home alone, getting into grocery
stores, or taking buses or elevators). You back off when your
anxiety becomes too great.
The If you're afraid of being alone, you can ask someone you
partnership feel safe with to walk a certain distance ahead of you and
method wait for you.
Then you walk and meet them there. The next time you ask
them to go a little farther, so you can gradually increase the
distance you can walk alone.
5. DAILY MOOD LOG Write down the negative thoughts that make you feel
anxious or frightened. Identify the distortions in these
thoughts and replace them with more realistic, positive
thoughts. Instead of worrying yourself sick by constantly
predicting failure and catastrophes, tell yourself that things
will turn out reasonably well.
6. THE COST- Make a list of the advantages and disadvantages of
BENEFIT worrying and avoiding whatever you fear. Weigh the
ANALYSIS advantages against the disadvantages. Make a second list
of the advantages and disadvantages of confronting your
fears. Weigh the advantages against the disadvantages.
7. POSITIVE IMAGING Substitute reassuring and peaceful images for the
frightening daydreams and fantasies that make you feel so
anxious.
8. DISTRACTION Distract yourself with intense mental activity (like working
on a Rubik's Cube), strenuous exercise, or by getting
involved in your work or a hobby.
9. THE ACCEPTANCE When you feel anxious or panicky, you may make matters
PARADOX worse y insisting that you shouldn't feel this way. This is like
throwing gasoline on a fire, and your anxiety gets worse.
One way to develop greater self-acceptance is to write out a
dialogue with an imaginary hostile stranger who puts you
down for feeling anxious. The hostile stranger is simply a
projection of your own self-criticism. When you talk back to
 them, you will develop greater self-acceptance, and your
anxiety will usually diminish or disappear.
10. GETTING IN TOUCH When you feel anxious or panicky, you are probably
ignoring certain problems that need to be dealt with.
Review your life and try to get in touch with the situation
that's making you feel so upset. When you find the courage
to deal with the problem more openly and directly, it can be
very liberating!
 THE BURNS DEPRESSION CHECKLIST
Name: Date:

1 = Somewhat

4 = Extremely
0 = Not At All
Instructions: Put a check ☑ to indicate how much you

Moderately
3 = A Lot
have experienced each symptom during the past week,
including today. Please answer all 25 items.

2=
Thoughts and Feelings
1 Feeling sad or down in the dumps
2 Feeling unhappy or blue
3 Crying spells or tearfulness
4 Feeling discouraged
5 Feeling hopeless
6 Low self-‐esteem
7 Feeling worthless or inadequate
8 Guilt or shame
9 Criticizing yourself or blaming others
10 Difficulty making decisions
Activities and Personal Relationships
11 Loss of interest in family, friends or colleagues
12 Loneliness
13 Spending less time with family or friends
14 Loss of motivation
15 Loss of interest in work or other activities
16 Avoiding work or other activities
17 Loss of pleasure or satisfaction in life
Physical Symptoms
18 Feeling tired
19 Difficulty sleeping or sleeping too much
20 Decreased or increased appetite
21 Loss of interest in sex
22 Worrying about your health
Suicidal Urges
23 Do you have any suicidal thoughts?
24 Would you like to end your life?
25 Do you have a plan for harming yourself?
Please Total Your Score on Items 1-‐25 Here:
 Total Score Level of Depression

No Depression 0-­‐5
Normal but unhappy 6-­‐10
Mild depression 11-­‐25
Moderate depression 26-­‐50
Severe depression 51-­‐75
Extreme depression 76-­‐100
 THE BURNS DEPRESSION INVENTORY
INSTRUCTIONS: The following is a list of symptoms that

2-MODERATELY
O-NOT AT ALL
people sometimes have. Put a check ( ) in the space to the

1-SOMEWHAT
right that bests describes how much that symptom or
problem has bothered you during this past week.

3-A LOT
SYMPTOM LIST
1. SADNESS: Have you been feeling sad or down in the
dumps?
2. DISCOURAGEMENT: Does the future look hopeless?

3. LOW SELF ESTEEM: Do you feel worthless or think of

yourself as a failure?
4. INFERIORITY: Do you feel inadequate or inferior to
others?
5. GUILT: Do you get self-critical and blame yourself for
everything?
6. INDECISIVENESS: Do you have trouble making up
your mind
about things?
7. IRRITABILITY AND FRUSTRATION: Have you been
feeling resentful and angry a good deal of the time?
8. LOSS OF INTEREST IN LIFE: Have you lost interest
in your
career, your hobbies, your family, or your friends?
9. LOSS OF MOTIVATION: Do you feel overwhelmed
and have to push yourself hard to do things?
1O. POOR SELF-IMAGE: Do you think you're looking old
or unattractive?
11. APPETITE CHANGES: Have you lost your appetite? Or
do you overeat or binge compulsively?
12. SLEEP CHANGES: Do you suffer from insomnia and
find it hard to get a good night's sleep? Or are you
excessively tired and sleeping too much?
13. LOSS OF LIBIDO: Have you lost your interest in sex?

14. HYPOCHONDRIASIS: Do you worry a great deal

about your health?
15. SUICIDAL IMPULSES: Do you have thoughts that life
is not worth living or that you might be better off
dead?

Add up your total score for the 33 symptoms and record

 it here.

DATE:

TOTAL DEGREE OF DEPRESSION

SCORE
O-4 Minimal or No Depression
5-1O Borderline Depression
11-2O Mild Depression
21-3O Moderate Depression
31-45 Severe Depression

WEEKLY CHECK LIST

Mon. Tues. Wed. Thur.

1. 1. 1. 1.
2. 2. 2. 2.
3. 3. 3. 3.
4. 4. 4. 4.
5. 5. 5. 5.
6. 6. 6. 6.
7. 7. 7. 7.
8. 8. 8. 8.
9. 9. 9. 9.
1O. 1O. 1O. 1O.
11. 11. 11. 11.
12. 12. 12. 12.
13. 13. 13. 13.
14. 14. 14. 14.
15. 15. 15. 15.
TOTAL
SCORE
TODAY'S
DATE