Adult History: Clinical Interview and Information Gathering Area Referral Problem (Why the person was referred

for testing) Adult Attachment Adult Client What to you hope to gain? What did you notice that led to the referral? Has there been prior testing and when? (Get copy before you start.) If chart is available or other data, read and incorporate rather than ask same questions all over again on personal information. Did you know you were going to be tested today? Who told you? What did they say? Why do YOU think you are being tested? 3 Adjectives to describe your relationship with your mother when you were a child. For each adjective, give an example. 3 Adjectives to describe your relationship with your father when you were a child. For each adjective, give an example. Which parent were you closer to and why? Do you remember any of the following when you were a child: being held by a parent, being comforted by a parent, being hurt or ignored by a parent, seeing your parents hurt each other As an adult, do you spend more time alone or with others? How do you deal with conflict in your adult relationships? Have you ever engaged or been involved in domestic violence? When you were a teen, were you a more of a loner or people person? Name people you have trusted with your most personal information. What is the longest period of time you lived on your own without being involved with someone? For you, is a relationship more about sex, avoiding loneliness, excitement or intimacy? If you went to a desert island and could take one person or one thing, what or who would you take with you? What kinds of people push your buttons? How do you respond? What do you enjoy doing with your friends? What kinds of people do you spend time with outside family? What do you like to do with others? Who do you NOT get along with? If you work, how do you get along with co-workers? Supervisor? How do you spend leisure time? Hobbies or sports? Belong to any clubs or organizations? Church or spiritual affiliation? Do you engage in any thrill-seeking or high risk activities? Do you prefer to be alone or with others?

Social & Recreational

Area Family Issues

Self- Image

Health Mental Physical Sleep / Appetite Eating Habits Illness & Injury Drug & Alcohol Sexual

Client What was it like growing up in your family? What kind of discipline did your parents use? Who were you closest to? Brothers and sisters? Are you more like your mother or father? What does your family do together to have fun? Who do you get along best with in your family? Who do you not get along with in your family? In your family, who are you most like? Least like? What do your parents do that you like? What do your parents do that you dont like? When people in your family get upset or mad, what do they do? History about marriage, relationships & divorce Any significant family changes / losses? When growing up, did you ever see your parents hurt one another physically, emotionally or verbally? On a scale from 1-10, with 1 being awful and 10 perfect, how good do you feel about yourself? If you could change one thing about yourself, what would it be? Do you compare yourself to others or get jealous easily? What do you like best about yourself? What are your strengths? What do you like least about yourself? What are your weaknesses? Family history of mental health problems? Significant family physical health problems? Your own history of MH treatment including any hospitalization. History of medications for health & psychiatric problems. Prescribed and non-prescribed. Significant head injury? Any loss of consciousness? Ever had seizures? Surgeries? Any problems with your memory? Recent or long ago? Problems getting lost or confused? Any changes in your thinking or speech (slurred, hesitation, etc.)? Serious physical illness or injury that resulted in hospitalization? Being treated for a diagnosed medical condition? Changes in stamina or physical functioning? Any painful medical condition? If yes, take any pain meds? How much? Ever run out early? When did you first taste alcohol? First use MJ or other drugs? What is your history of alcohol & drug use? Ever have charges for DUI or Public Intoxication (PI)? Pregnancies and details? Births? Any problems or changes in sleep or appetite? Hours sleep per night? Getting to sleep? Staying asleep? Waking early? Wake up unrested? Nightmares? Night terrors? Sleep hygiene bedtime, naps, caffeine in PM, exercise before bed History of Binging / Purging? Weight Loss or Gain? Change in sexual drive or performance?

Area Vocational / Educational

Emotional: Mood Regulation / Feelings

Client Did you finish HS? If not, when did you drop out and why? Post-high school education? GED? What was your favorite class / subject at school? What was hard for you to do at school? What were your grades like? Did you have discipline problems at school (ISAP, suspension, etc.) Ever stay back a grade? How did you feel about that? When did school start to get harder for you? Why do you think school was hard for you? Can you pay attention OK? Did you ever daydream during class? Ever in a special class at school? Jobs longest job held? How many jobs in the last 5 years? If on disability, how long and why? Favorite job ever? Ever been involved in Vocational Rehabilitation? Ever fired from a job? Are you moods more even or variable? When you are upset, what do you do to calm down? Do you ever have trouble controlling your emotions? Give an example. Do get upset faster than others do? Have you ever said or thought you wanted to die? Ever thought about hurting anyone else? Ever had protective order (DVO, EPO) taken out against you? Ever hurt someone when you were upset? Ever felt such strong feelings that you hurt yourself (cutting, hit self, etc.) or wanted to hurt yourself? Do have trouble leaving the house? How do you feel in crowded places? Are you a worrier? What do you worry about? Have you lost interest in things you used to enjoy? What do you experience when you get anxious? What do you experience when you get depressed? Ever had periods of time when you could not sleep, your mood was really up, and you had more energy than usual? Ever had periods of times when you were very restless or irritable? Ever felt suspicious of others for no real reason? Do you accuse others of doing or thinking things? Fears? Specific or general? Do your fears stop you from doing things you would like to do?

Area Developmental / Sensory Integration Issues

Client Pregnancy & Delivery (if known): Were you born early, late or on time? Problems in pregnancy, labor or delivery? Did mother smoke, drink or use drugs during pregnancy? Type of delivery (vaginal, C Section & why) Did you come home from the hospital same time as mom? Are there certain foods you like and dont like to eat? Certain clothes you like and dont like to wear? Certain noises that really bother you? Anything hard for you to do with your hands or body due to lack of coordination (handwriting, ride bike, run, etc.)?