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Kitti Virts, Ph.D.
Clinical Psychologist

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BIOGRAPHICAL INFORMATION

Instructions: To assist me in helping you, please fill out this form as fully and openly as possible. All private information is held in strictest confidence. Form cannot be saved to finish later, so please allot enough time to complete it.

Date of first appointment:

Demographic & Contact Information

First Name

Age

Last Name

Birthday

Address

Home Phone

Cell Phone

# Years of education

Present Marital or Partnership Status

Do you have children? If yes, please list ages and gender

Work Phone

Email (if I have your permission to email you):

Occupation

If married or in a long-term relationship, number of years with present spouse or partner:

Emergency Contact: Name, Relationship, Phone

Reason for Today’s Visit

What is (are) your main reason(s) for this visit?

Symptoms

Check boxes below for symptoms that have been frustrating to or otherwise problematic for you during at least the last two weeks:

decreased appetite

increased appetite or craving

weight changes

increased need for sleep

difficulty sleeping

sexual difficulties

fatigue or decreased energy

decreased interest in usual activities

decreased motivation or drive

decreased pleasure

social withdrawal

decreased confidence or self-esteem

blue, sad, or depressed mood

feeling guilty

crying spells

apathetic or flattened mood

hopelessness

Thoughts of harming yourself

Cutting or severely scratching yourself

suicidal thoughts

feeling tense, jittery, or shaky

muscle tightness or pain

headaches

GI distress

worries

general anxiety or apprehension

specific fears or phobias

anxiety or panic attacks

increased heart rate or palpitations

rapid breathing or shortness of breath

chest tightness, pressure, or pain

sweating

dizziness

feeling unreal or dreamlike

numbness or tingling in hands or feet

recurrent intrusive thoughts or memories

nightmares

hyper-vigilance/feeling on-guard

hyper-startle response

irritability or annoyance

feeling angry

rageful or flying-off-the-handle

impulses of physical aggression

thoughts of harming someone

impulsive or rash behavior

racing thoughts

mood shifts

alcohol use

drug use

concentration problems

memory problems

problems judging or making decisions

disorientation

losses of time

feeling zoned-out or disconnected from reality

feeling separate from your body

feeling in a childlike state

purposefully restricting food intake

emotional overeating

eating to uncomfortably full or binge eating

purging to avoid weight gain

excessive exercise

obsessive thoughts

compulsive behavior

thoughts disorganized

speech problems

hearing or seeing things others do not

Other (specify)

Alcohol/Substance Use

Current use of each:

# Alcoholic drinks per week

Frequency of marijuana use

Other substances used

Have you ever felt the need to cut down your drinking or drug use?

Have you ever had guilty feelings about drinking or drug use?

Have you ever felt annoyed by criticism of your drinking or drug use?

Have you ever had a drink or used drugs first thing in the morning to ease your nerves or get rid of a hangover?

Counseling History

Have you received counseling in the past?

If Yes, approximately when, for how long, and for what issues:

Medical History

Name of your primary physician

Office location/city

Current medical issues or illnesses

Current Chronic pain?

If Yes, location(s) of pain

Average severity of pain (0-10 scale, 0=no pain, 10=worst pain imaginable

Past major illnesses &/or operations

Current Medications, Dosages, Purposes

Allergies to what medications

Family/Developmental History

Were you adopted or raised with parents other than your biological parents?

Mother’s past or current occupation

Father’s age, or if deceased, how old were you when he died?

Father’s medical illnesses?

Mother’s age, or if deceased, how old were you when she died?

Mother’s medical illnesses?

Father’s past or current occupation

If your parents are separated or divorced, how old were you then?

I was child number_____ in a family of _____children.

Number of brother(s) & their ages

Number of sisters(s) & their ages

Family members/relatives with history of mood, anxiety, alcohol, drug, &/or other mental problems:

Please check any of the following you experienced during childhood:

parental/caretaker alcohol &/or substance abuse

neglect

recurrent criticism

name calling or other emotional abuse

corporal punishment or physical abuse

inappropriate touch or sexual abuse

recurrent arguing or domestic violence in home

recurrent bullying or teasing in school or elsewhere

Other major stressful life events and approximate age when they occurred:

Any other information you think might be helpful for me to know to facilitate your care:

Thanks for submitting!

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