CBRTP New Patient Evaluation Packet

Name: __________________________________________________________________

Date/Time of Evaluation: ___________________________________________________

Therapist: _______________________________________________________________

Supervisor: ________________________________

Dear New Patient,

We look forward to working with you at the Cognitive Behavioral Research and

Treatment Program (CBRTP). To provide you with high quality care, please complete the

following questionnaires. This is the first part of your evaluation today. The information

you provide will enable us to plan the most effective treatment for you. If you have any

questions about this packet, please ask your therapist when you begin the interview part

of your evaluation. Your therapist will return in approximately thirty minutes.

Thank you.

CBRTP

Consent for Treatment at the CBRTP

The psychotherapy that you will receive at the Cognitive Behavioral Research and

Treatment Program (CBRTP) will consist of meetings with a therapist who will assist

you in setting and working towards goals for desirable changes in how you live your life.

Therapy sessions will generally occur once per week or on a schedule mutually agreeable

to you and the therapist. There are minimal risks associated with this form of

psychotherapy. Potential benefits include positive changes in individual functioning and

couple interactions that may result in decreases in general distress or specific symptoms.

The CBRTP is committed to providing high quality services within the context of a

teaching and training clinic. Attending level psychologists at Duke University Medical

Center are providers of record. Trainees (e.g., psychiatrists, post-doctoral psychologists,

medical psychology interns in their last year of training, and advanced clinical

psychology graduate students) within the CBRTP work closely under the supervision of

attending level psychologists when providing psychotherapy services. To provide the best

possible care, the CBRTP has therapy rooms equipped with unobtrusive cameras that can

record your sessions and be used for supervision in order to enhance clinical care. If you

are unwilling to allow your therapist to videotape your session, we will still work with

you to provide services in most circumstances. Videotapes of sessions are recorded over

generally once per week, are stored in a locked desk in the clinic, and are only used for

the purpose of ensuring the highest quality delivery of services. Your therapist will talk

with you early on in treatment about this, and you will have opportunities to discuss and

resolve any concerns.

The confidentiality of information obtained during assessment and therapy sessions will

be guarded except where proscribed by law. Possible legal exceptions to confidentiality

may occur if necessary to protect individuals from child abuse and neglect, or in cases of

potential harm to oneself or others. In such cases, confidentiality would only be broken

in order to protect individuals from significant harm or death.

Detailed information contained in the medical record can only be released with the

written permission of all parties to the therapy. Certain information is stored in an

electronic record. This information (demographic information, diagnoses, medications,

drug allergies, progress notes) is accessible to other doctors or professionals who may

have need to be involved with your care; for example, emergency room doctors; doctors

or clinicians who are covering for your therapist, etc.) The purpose of this is to protect

you from medication errors or other clinical errors by doctors or therapists who may

become involved with your care. The storage of this information in an electronic record

is mandated by federal regulations, applies to all clinicians in the United States, and is

intended to provide you with the most thorough and informed treatment.

I have had a chance to ask questions about the above and my questions have been

answered. If I have any questions in the future, I know that I can contact Dr. Zach

Rosenthal (Clinic Director) at (919) 684-6702 or Marissa Howard, LCSW (Treatment

Coordinator) at (919) 684-6718.

____________________________________ _____________________

Signature Date

____________________________________

Printed name

____________________________________

Witness

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Psychiatric Evaluation Intake Form 1. Patient Contact Information Patient Name_________________________________________ Preferred Name ____________________

Last First MI

Address_______________________________________________________________________________ Best contact phone number: ____________________ Email address: ______________________________ Primary Care Physician: _________________________Tel: __________________ Fax________________ Pharmacy: __________________________________ Phone #: ___________________________________

2. Date of Birth: ______/_______/_______ 3. Age: _________(yrs.) 4 How do you describe your race and/or ethnicity? __________________

5. What was/were the primary languages spoken in your house growing up? ____________________ 6a. What is your current gender? _____________ 6b. What was your gender assigned at birth? _____________ 6c. What are your preferred gender pronouns? (e.g., she, her, hers) _________________ 7. How do you describe your sexual orientation? ______________________ 8. How do you describe your religious or spiritual beliefs? ______________________ 9. Current marital status (Check one): Single, never married Married, living together Separated Widowed Cohabiting with partner Divorced Married, not living together

10. Formal Education Level: (Check all that apply) Completed some High School High school graduate G.E.D. 4 year college degree Master’s Degree (Please specify:_____________) Doctoral Degree (Please specify:_____________) Junior college degree or technical school diploma J.D./LL.B. Other____________________

11. What best describes your current employment status? (Check one from each category a, b, & c) a. Employment Status Unemployed, not looking for employment Unemployed, looking for employment Full-time employed Part-time employed Retired Self-employed

b. Student Status Part-time Full-time Not a student

c. Volunteer Status Volunteer Part-time Volunteer Full-time d. Benefits Receiving Government Assistance (Please specify): )

12. What is your occupation? ____________________________________________________________

13. Please briefly state the reason for your visit today: ____________________________________________________________________________________________________________________________________________________________________________

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14. Do any of the following apply to you?

____ Problems with family or friends

____ Emotional problems

____ Occupational problems

____ Housing problems

____ Economic problems

____ Substance use problems

____ Problems with access to health care services

____ Problems related to interaction with the legal system/crime

____ Problems related to adjusting to new environment and/or country

____ Other psychosocial and environment problems

____ History of traumatic experiences (physical, sexual, emotional, psychological, or other)

15. How were you referred to our clinic?

By my physician (name): _______________________________ Self-referred Other: ____________

16. Are you currently receiving mental health care (i.e. individual therapy, couples therapy, substance use treatment, etc.)? YES NO

(If yes) Provider’s name: _________________________________ Duration: _________________________

17. Have you ever seen a psychiatrist/psychotherapist before? YES NO

Name: _____________________________________ Start Date/Duration: __________________________ Name: _____________________________________ Start Date/Duration: __________________________

18. Previous personal mental health history and family member mental health history: Have you ever been treated and/or diagnosed for any of the following (check all that apply) and/or have your biological family members even been treated and/or diagnosed for any of the following (check all that apply):

Personal mental health history (Check all that apply)

Family members’ mental health history (write member and which side of the family; i.e.

“Maternal grandmother”)

Depression

Anxiety

Panic Attacks

Obsessive Compulsive Disorder

Post-Traumatic Stress (PTSD)

Bipolar Disorder

Schizophrenia

Personality Disorders

Alcohol Problems

Substance Use Problems

ADHD

Eating Disorders

Note: Your clinician will follow-up on

endorsed items.

If you are unsure or would prefer to discuss verbally, please let your

clinician know.

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Phobias

Gender Dysphoria

Others not listed

19. Have you ever had ECT (electroconvulsive therapy)? YES NO

20. Have you ever been hospitalized for psychiatric reasons? YES NO

If yes, please provide details below:

Approx. Date Length of Stay Name of Hospital Reason for Admission

21. Have you ever planned and/or attempted to kill yourself? YES NO

If yes, how many attempts? ________ If yes, please list the occurrences below (if more than 3 please list the 3 most recent attempts):

Approx. Date of Attempt How did you attempt? (Method)

22. Have you ever deliberately harmed yourself without the intent to die? YES NO More than 3 times If yes, please list the occurrences below (if more than 3 please list the 3 most recent time this happened):

Approx. Date How did you harm yourself? (Method)

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23. If you DO NOT obtain your health care at Duke, please list ALL current medications below. If you DO receive your health care at Duke, you may skip this section as your medications are already in your medical record. Include birth control, over the counter medication, and herbal remedies (decongestants, St. John’s Wort, etc)

Name of Medication Dosage (Mg)

How many

times per day? On this for how long?

Side effects (if any)

Prescribing Physician

24. Do you take your medication each day as prescribed? YES NO 25. Medical History: Do you have, or have you ever had any of the following? Please check all that apply. High Blood Pressure Seizures

Lung Disease Gastrointestinal Problems (ulcers, pancreatitis, irritable bowel, colitis)

Diabetes Arthritis or Rheumatoid Problems

Heart Disease Liver Damage or Hepatitis

Thyroid Disease Other Endocrine/Hormone Problems

Anemia Neurological Problems (stroke, brain tumor, nerve damage)

Asthma Gynecological / hysterectomy

Skin Disease Viral Illness (herpes, Epstein-Barr, chronic hepatitis)

Cancer Head Injury or Traumatic Brain Injury

Genital Problems Urinary Tract or Kidney Problems

Eating Disorder Migraine or Cluster Headaches

Eye Problems Ear/Nose/Throat Problems

Chronic pain HIV Positive or AIDS

Fibromyalgia High Cholesterol

Sleep apnea Allergies

26. When was your last alcoholic drink? ___________________________________________________

27. About how many days in the past month have you had at least one drink? ___________________ 28. What is the maximum number of drinks you have had in one day in the past month? ___________

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29. Please indicate your history of substance use:

Never Used

Age First Used

Age Peak Use

Last Used on This Approx.

Date

Current Use and Frequency

Cigarettes or Cigars

Smokeless Tobacco

Caffeine (Coffee, Tea, Soda)

Marijuana

Benzodiazepines (Xanax, Valium, Ativan, Restoril)

Opioids (Vicodin, OxyContin, Percocet, morphine, codeine,

fentanyl)

Pain Pills

Sleeping Pills

Diet Pills

Amphetamines and/or Speed

Cocaine

Hallucinogens (LSD, Mushrooms, Mescaline)

Ecstasy

Laxatives

PCP or Angle Dust

IV Drug Use

Heroin

GHB

Anabolic Steroids

Other

30. If you currently use any of the substances listed above, is it within your treatment goals to quit? YES NO

31. Is there anything else you would like your treatment provider to know about you or your reason for treatment?

PHQ-9 Instructions: Over the last 7 days, how often have you been bothered by any of the following problems?

Not at

all Several

days More than

half the days

Nearly every day

1. Little interest or pleasure in doing things 0 1 2 3

2. Feeling down, depressed, or hopeless 0 1 2 3

3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3

4. Feeling tired or having little energy 0 1 2 3

5. Poor appetite or overeating 0 1 2 3

6. Feeling bad about yourself—or that you are a failure or have let yourself or your family down 0 1 2 3

7. Trouble concentrating on things, such as reading the newspaper or watching television 0 1 2 3

8. Moving or speaking so slowly that other people could have noticed? Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual

0 1 2 3

9. Thoughts that you would be better off dead or of hurting yourself in some way 0 1 2 3

LEC-5 Listed below are a number of difficult or stressful things that sometimes happen to people. For each event check one or more of the boxes to the right to indicate that: (a) it happened to you personally; (b) you witnessed it happen to someone else; (c) you learned about it happening to a close family member or close friend; (d) you were exposed to it as part of your job (for example, paramedic, police, military, or other first responder); (e) you’re not sure if it fits; or (f) it doesn’t apply to you. Be sure to consider your entire life (growing up as well as adulthood) as you go through the list of events.

Event

Happened to me

Witnessed it

Learned about it

Part of my job

Not Sure

Doesn’t Apply

1. Natural disaster (for example, flood, hurricane, tornado, earthquake)

2. Fire or explosion

3. Transportation accident (for example, car accident, boat accident, train wreck, plane crash)

4. Serious accident at work, home, or during recreational activity

5. Exposure to toxic substance (for example, dangerous chemicals, radiation)

6. Physical assault (for example, being attacked, hit, slapped, kicked, beaten up)

7. Assault with a weapon (for example, being shot, stabbed, threatened with a knife, gun, bomb)

8. Sexual assault (rape, attempted rape, made to perform any type of sexual act through force or threat of harm)

9. Other unwanted or uncomfortable sexual experience

10. Combat or exposure to a war-zone (in the military or as a civilian)

11. Captivity (for example, being kidnapped, abducted, held hostage, prisoner of war)

12. Life-threatening illness or injury

13. Severe human suffering

14. Sudden violent death (for example, homicide, suicide)

15. Sudden accidental death

16. Serious injury, harm, or death you caused to someone else

17. Any other very stressful event or experience

PLEASE COMPLETE PART 2 ON THE FOLLOWING PAGE

PART 2:

A. If you checked anything for #17 in PART 1, briefly identify the event you were thinking of:

__________________________________________________________________

B. If you have experienced more than one of the events in PART 1, think about the event you consider the worst event, which for this questionnaire means the event that currently bothers you the most. If you have experienced only one of the events in PART 1, use that one as the worst event. Please answer the following questions about the worst event (check all options that apply):

1. Briefly describe the worst event (for example, what happened, who was involved, etc.).

________________________________________________________________________________________

________________________________________________________________________________________

2. How long ago did it happen? ____________________ (please estimate if you are not sure) 3. How did you experience it?

____ It happened to me directly

____ I witnessed it

____ I learned about it happening to a close family member or close friend ____ I was repeatedly exposed to details about it as part of my job (for example, paramedic, police, military, or other

first responder)

____ Other, please describe:

4. Was someone’s life in danger?

____ Yes, my life

____Yes, someone else’s life

____No

5. Was someone seriously injured or killed?

____ Yes, I was seriously injured

____ Yes, someone else was seriously injured or killed

____ No

6. Did it involve sexual violence? ____Yes ____No

7. If the event involved the death of a close family member or close friend, was it due to some kind of accident or violence, or was it due to natural causes?

____ Accident or violence

____ Natural causes

____ Not applicable (The event did not involve the death of a close family member or close friend)

8. How many times altogether have you experienced a similar event as stressful or nearly as stressful as the worst event?

____ Just once

____ More than once (please specify or estimate the total # of times you have had this experience _____)

PLEASE COMPLETE PART 3 ON THE FOLLOWING PAGE

Part 3: Below is a list of problems that people sometimes have in response to a very stressful experience. Keeping your worst event in mind, please read each problem carefully and then circle one of the numbers to the right to indicate how much you have been bothered by that problem in the past month. In the past month, how much were you bothered by:

Not at all

A little bit

Moderately

Quite a bit

Extremely

1. Repeated, disturbing, and unwanted memories of the stressful experience? 0 1 2 3 4

2. Repeated, disturbing dreams of the stressful experience? 0 1 2 3 4

3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?

0 1 2 3 4

4. Feeling very upset when something reminded you of the stressful experience? 0 1 2 3 4

5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?

0 1 2 3 4

6. Avoiding memories, thoughts, or feelings related to the stressful experience? 0 1 2 3 4

7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?

0 1 2 3 4

8. Trouble remembering important parts of the stressful experience? 0 1 2 3 4

9. Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?

0 1 2 3 4

10. Blaming yourself or someone else for the stressful experience or what happened after it? 0 1 2 3 4

11. Having strong negative feelings such as fear, horror, anger, guilt, or shame? 0 1 2 3 4

12. Loss of interest in activities that you used to enjoy? 0 1 2 3 4

13. Feeling distant or cut off from other people? 0 1 2 3 4

14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?

0 1 2 3 4

15. Irritable behavior, angry outbursts, or acting aggressively? 0 1 2 3 4

16. Taking too many risks or doing things that could cause you harm? 0 1 2 3 4

17. Being “superalert” or watchful or on guard? 0 1 2 3 4

18. Feeling jumpy or easily startled? 0 1 2 3 4

19. Having difficulty concentrating? 0 1 2 3 4

20. Trouble falling or staying asleep? 0 1 2 3 4

LEC-5 (10/27/2013) Weathers, Blake, Schnurr, Kaloupek, Marx, & Keane -- National Center for PTSD

PCL-5 (8/14/2013) Weathers, Litz, Keane, Palmieri, Marx, & Schnurr -- National Center for PTSD