About Dr. Warsaw
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George Warsaw, Ph.D. Counseling Psychotherapy Coaching
About Dr. Warsaw
HOME
Client Information
Couples Counseling Questionaire
Contact Me
Inventory Self
My Reviews
Office Info
Client Information
Name
*
First Name
Last Name
Maiden/Previous
Age / Sex
*
Email
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Cell
*
(###)
###
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Home
(###)
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Work
(###)
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Physician / Date of last complete physical exam
Employer / Occupation
Education
1 – I didn’t finish high school
2 – GED/Diploma
3 – College
4 – Post Graduate
Marital Status
# of Children Names / Ages
Spouse’s/partner’s name / Age
Spouse’s employment / Work Phone
Previous marriages and for how long?
Is this the first mental health contact? If no, when was the first contact?
*
Since then, how many sessions? The most recent was:
Previous treatment (check all that apply)
Individual
Couple
Family
Group
What were the goals? Were goals achieved? If no, why not?
What brings you to us today?
*
Symptoms you have been displaying
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Difficulty Sleeping: Beginning
*
Yes
No
Difficulty Sleeping: MIddle
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Yes
No
Difficulty Sleeping: Early Wake Up
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Yes
No
Energy Level
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Excess
Adequate
Low
Very Low
Appetite
*
Excess
Adequate
Low
Very Low
Do you have feelings of guilt? If so, about what?
*
Do you have repeated, unwanted thoughts? If so, about what?
*
Current medications (include dosage, frequency and when you started):
*
Hospitalizations: (Year and reason)
*
Surgeries: (Year and reason)
Serious illness(es)
*
Drinking: # of drinks? How often? Type of drinks?
*
Smoking: Yes/No, If Yes, # packs per day? # of yrs? Date quit?
*
Illicit drugs used (none) date(s), types, and Frequency:
*
Family Mental Health History (Family Member/Problem)
*
Work History
*
1 - employed in the same field for many years:
2 - held many jobs or career changes
3 - had difficulty adjusting to work
4 - never held a steady job
5 - now medically or physically disabled
Longest job
*
Traumatic experiences:
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Difficulty with memory? Yes/No If Yes, please explain
*
Depression: Yes/No If Yes, for how long
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Anxiety: Yes/No If Yes, for how long
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Do you have any suicidal ideas or intentions? Yes/No If Yes, please explain
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Homicidal ideas or intentions? Yes/No If Yes, please explain
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Death wishes? Yes/No If Yes, please explain
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Arrest record: Yes/No If Yes, for what
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Did you run away as a child? Yes/No If Yes, please explain
*
Did you have any problems in school? Yes/No If Yes, please explain
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Do you have a personal support system? Names and Relationship
*
Person to contact in case of emergency (Relationship, Address Phone, and Number)
*
Thank you!