Adult Client Questionnaire

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Adult Client Questionaire

Adult Client Questionaire
  • INSTRUCTIONS: Please complete the following information. Please be fully honest in all of your responses as this will assist the most in understanding your difficulties. This information will be kept confidential as outlined in the Informed Consent Policy. If you are not certain how to answer a question please leave it blank and discuss it with Dr. Carey during your interview. If you are completing the questionnaire for a child, please answer all of the questions from the child’s perspective. Thank you for taking the time to complete this important information.

  • Demographic Information
  • Phone Number(s):

  • Developmental History
  • Please answer the following to the best of your knowledge. If you do not know the answer, please leave blank.

  • Family History
  • Siblings
  • How would you rate your current relationship with the following persons?
  • If you have ever been divorced, please complete the following:

  • Education

  • Employment

  • Legal History
  • Substance Usage History
  • Medical
  • Community Involvement
  • Mental Health History
  • Current Issues