PREMIER PSYCHOLOGICAL CENTER ADULT FORM (18 and older) The following information is very important and needed to fully complete your evaluation. Please answer each question thoroughly and provide specific details when necessary. Feel free to write on the back or to ask for extra paper if needed. If there are any questions, please ask Dr. McAdams or her staff. Client Full Name: ________________________________________________Birth Date: _______________ Age: ________ Address: _____________________________________________ City

_____________________________________________Race/Cultural Group: ______________________________

Home Phone: ___________________ Sex:

(please circle)

Male

Cell: __________________

Female

Work: ______________________________

Height? _________

Circle Marital Status: Single-(never-married)

Married

Separated

Divorced

Weight? ___________ Widowed

Living with someone

Spouse’s Name: _________________________ Age: __________Birth Date: ____________ Date Married? _____________

YOUR CHILDREN (minor and adult): NAME

AGE

SEX

OCCUPATION OR GRADE

LIVING WITH CLIENT?

BIOLOGICAL, ADOPTED OR STEP

Do you have any concerns about your children? [ ] No

[ ] Yes

If so, would you like for them to be evaluated? [ ] No

[ ] Yes If yes, please provide insurance information below.

Insurance Company _______________________________________________ Member ID #___________________________ Insurance contact number __________________________________________

Number of Brothers and Sisters____________

Do any of your siblings receive disabilty funds? Yes[ ] No [ ] If yes, for what reason? ______________________________

Who did you grow up with (in the same home)? ___________________________________________________

Premier Psychological Center Clinical Interview Questions Page 2

Describe your relationship with: Parents:_______________________________________________________________________________________ Siblings: ________________________________________________________________________ Extended Family Members: _______________________________________________________________________ Husband/Wife/Significant Other: ___________________________________________________________________ Your Children: _________________________________________________________________________________

Your parents are: [ ] Married Your parents are:

[ ] Divorced

[ ] Birth Parents

[ ] Separated

[ ] Step Parents

[ ] Never Married

[ ] Adoptive Parents

Father’s Name: __________________________________________Age: _______ If Deceased, Date:___________________ Occupation: ___________________________________________Highest Grade Level: ______________________________ Mother’s Name ___________________________________________Age: _______ If Deceased, Date: __________________ Occupation: __________________________________________Highest Grade Level: _______________________________

How did you get to this appointment today? [ ] Drove [ ] Dropped Off

[ ] Public Transportation [ ] Walked/Bicycle

Did anyone accompany you today? [ ] Yes [ ] No

If yes, what is their name and relationship to you? Name _____________________________ Relationship________________

Do you want them to be interviewed with you? [ ] Yes [ ] No

Purpose of Visit Why have you applied for SSI Disability Assistance? Please describe in DETAIL.

Psychiatric Do you experience frequent periods of sadness or lack of enjoyment? Please describe.

Premier Psychological Center Clinical Interview Questions Page 3

Are you currently receiving counseling? If yes, what is the reason?

If no, have you ever received counseling in the past? When?

What was the reason?

Have you ever been placed in a psychiatric hospital? When and explain why

Are you currently having suicidal thoughts? Please Explain.

Have you had any suicidal thoughts in the past? If yes, when?

Have you ever done anything to harm or kill yourself? If yes, please explain in detail

Do you intend to harm yourself in any way ? If yes, please explain.

Do you have plans of harming anyone else? If yes, please explain.

Do you or have you ever had hallucinations (for example, hear voices or see things that others do not see)? If yes, please explain.

Do you frequently feel nervous or fearful? Please explain.

Premier Psychological Center Clinical Interview Questions Page 4

Do you experience panic attacks (sudden attacks of fear or anxiety)? [ ] Yes [ ] No

If yes, please describe what happens when you have panic attacks.

Do you often find yourself angry or irritable? If yes, how do you act when you’re angry?

Do you physically fight others? [ ] Yes [ ] No If yes, when was the last time you fought and explain what happened.

Have you lost friends and/or relationships because of your anger? [ ] Yes [ ] No If yes, please explain.

Medical Please list any medical issues and when you were diagnosed with each. Medical Issues

Do you have any problems with walking? Bending? Lifting? If so, please explain.

Please list all medications.

Date Diagnosed

Premier Psychological Center Clinical Interview Questions Page 5

Employment Are you employed? If yes, Where do you work?

How long have you been working there?

What are your duties?

Are there any problems noted on the job? Describe

Do you get along with coworkers?

If unemployed, Date when last employed?

Where did you work and how long were you there?

(c) Were there any problems noted on the job? Please describe.

(d) Did you get along with coworkers?

(e) Reason for leaving?

List other jobs in the past 10 years, dates worked, and reason for leaving:

Job (place and your position)

Dates Worked

Do you have any income? Yes [ ] No [ ] If yes, how much per month? _________

Reason for Leaving

Premier Psychological Center Clinical Interview Questions Page 6

Education What is your last grade completed?

Did you repeat a grade? Yes [ ] No [ ] If yes, what grade(s)?

Special education classes? Yes [ ]

_____________________

No [ ]

Do you have any additional education/training (i.e. certificates)?

Substance Use 1.

Do you drink alcohol? [ ] Yes [ ] No

If yes, How much do you drink?

If No, did you drink in the past? How much did you drink?

How often do you drink (i.e. once a week)?

2.

How often did you drink (i.e. once a week)?

Do you use drugs (i.e. marijuana, cocaine, methamphetamine) [ ] Yes [ ] No

If yes, How much ?

If No, did you use drugs in the past? How much?

How often (i.e. once a week)?

How often (i.e. once a week)?

When did you last use any drugs (i.e. today, two weeks ago)?

When did you last use any drugs (i.e. today, two weeks ago)?

3.

Have you ever been in a substance abuse program (e.g. drug or alcohol)? If yes, when?

4.

Do you smoke cigarettes? [ ] No

If yes, How much? How often (i.e. daily, every two days)?

[ ] Yes If No, did you smoke cigarettes in the past? How much? How often (i.e. daily, every two days)?

Legal Have you ever had a legal charge related to alcohol or other drugs (i.e. DUI)? [ ] No [ ] Yes

If yes, explain.

Premier Psychological Center Clinical Interview Questions Page 7 Have you ever been in jail? If yes, When? List charges below: (1) (2) (3) Have you ever been to prison? If yes, When? List Charges below: (1) (2) (3)

Are you currently on probation or parole? Explain.

Do you have family members with mental health or substance abuse problems? [ ] No [ ] Yes If yes, explain who and what type of problems: ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________

Daily Activities Where do you live? [ ] Apartment [ ] Single Family Home [ ] Mobile Home [ ] Rooming House [ ] Halfway house Do you rent or own?

How long have you lived at your present address?

*If less than a year, where and with whom did you previously live? Please list below current household members: NAME

AGE

SEX

RELATIONSHIP TO CLIENT

Premier Psychological Center Clinical Interview Questions Page 8 Have you ever been homeless? If so, please answer the following questions: Why are/were you not able to stay with family or friends?

Where do/did you stay when it was too hot or cold to stay outdoors?

How do/did you get money for transportation, medicine, etc.?

Do you have sleep problems? Please explain.

Do you nap during the day?

How do you spend your morning and afternoons (for example, watch TV, talk to friends, clean house)?

Do you have appetite problems? Please explain.

What are your hobbies (movies, dining out, etc.)? Describe in detail.

How often do you participate in hobbies?

Do you have friends? [ ] Yes [ ] No

*If yes, how often do you spend time with them?

What do you do with them?

If you do not have friends, please explain why?

Premier Psychological Center Clinical Interview Questions Page 9 INFORMATION ABOUT YOUR DAILY ACTIVITIES

Do you have difficulty doing any of the following? (Please explain any “Yes” answers.) Bathing/Dressing

 No

 Yes

Taking medicine

 No

 Yes

Preparing meals (Cooking)

 No

 Yes

Feeding self

 No

 Yes

Doing chores (inside/outside house)

 No

 Yes

Do you have a driver’s license?

 No

 Yes

Own Transportation ?

If no transportation, how do you get around?

Shopping for clothes or groceries

 No

 Yes

Seeing, hearing, or speaking

 No

 Yes

Managing money (Pay bills, buy clothes, etc.)

 No

 Yes

Concentrating

 No

 Yes

Memory

Understanding/following directions

 No

 Yes

 No

 Yes

 No

 Yes

Premier Psychological Center Clinical Interview Questions Page 10

Do Not write below this line. For Official Use Only.

Affect:

Orientation:

Reasoning:

Physical D:

Speech:

SI/HI or V/A:

Gross/Fine Motor:

R/R Memory:

Insight & Jud:

Effort:

Attention:

Reliability:

Est. Intell.

Driver’s License: [ ]current [ ]expired

Additional Notes

[ ] ID Only