Terms and Conditions This form is the expression of my voluntary and informed consent to engage in professional social work services, in the context of a psychosocial interview. I understand that I may withdraw from the social work service at any time. Further, I understand that information and records are kept in a secure and confidential manner. I further understand that following my conversation with Your Counselling Ltd/ Jeffrey Sturgeon a summary report will be made available to the fertility clinic, or the consultant agency, that I am working with. I understand that the summary report then becomes the property of the fertility clinic and any further disclosure of the aforementioned report will be made in accordance with their disclosure policies. I understand that Your Counselling Ltd. does not retain copies of the report but rather the intake notation and information only. I further understand that the summary report will be transmitted to the clinic. via a PDF document and attached to an electronic mail message. Further to this, I release Jeffrey G. Sturgeonwith any liability associated with further transmission and disclosure. I understand that should I wish to obtain a copy of the report I will have to request it from the referring agency and or clinic. By selecting the box and typing my name below, I understand that it is if I am signing in person. I further understand that consent will be verbally reviewed prior to engagement in any social work intervention.Agreement & Understanding I understand the above information I consent to engage in the Psychosocial InterviewFirst Name Last Name Email What is the date/time of your session with our Agency? Patient Age Patient Gender - Select -MaleFemaleOthersPhone no. What is your current employment situation? Check all that apply: Employed and satisfied Employed but dissatisfied Unemployed Coworker conflicts Supervisor conflicts Unstable work history Disabled OtherIf currently employed, what is your occupation: Do you enjoy your work? How many hours a day do you work? Do you take work home with you? Marital Status: Single Married Domestic Partner Separated Divorced WidowedRelationship satisfaction: Very satisfied Satisfied Somewhat satisfied Dissatisfied Very dissatisfiedDescribe any past or current significant issues in your intimate relationships: Family InformationPlease describe your childhood family experience: Outstanding home environment Chaotic home environment Experienced physical/verbal/sexual abuse from others Normal home environment Witnessed physical/verbal/sexual abuse toward others OtherPresence of Mother during your childhood: - Select -Present entire childhoodPresent part of childhoodNot present at allDon't havePresence of Father during your childhood: - Select -Present entire childhoodPresent part of childhoodNot present at allDon't havePresence of Stepmother during your childhood: - Select -Present entire childhoodPresent part of childhoodNot present at allDon't havePresence of Stepfather during your childhood: - Select -Present entire childhoodPresent part of childhoodNot present at allDon't havePresence of Brother during your childhood: - Select -Present entire childhoodPresent part of childhoodNot present at allDon't havePresence of Sister during your childhood: - Select -Present entire childhoodPresent part of childhoodNot present at allDon't haveParents' current marital status. If a parent is no longer alive, please indicate the parent's marital status before passing: Married to each other Separated Divorced Mother Re-married Father Re-married Mother involved with someone Father involved with someoneFeel free to add extra pertinent information about your family in the box below: List all persons currently living in your household: List children (yours / your partner's) not living in the same household as you: Medical HistoryWho is your primary care doctor: Which medications (psychotropic or not) are you currently taking? allergic to any medications Yes Noallergic to any medications Regarding your childhood, which - if any - of the following conditions did you suffer from? Please use the boxes to indicate the approximate age when affected by such conditions and/or to further specify them: Autism Chicken Pox Chronic, serious health problems Diphyheria Ear infection German measles Lead poisoning Mumps Pneumonia Poliomyelitis Red measles Rheumatic fever Scarlet fever Significant injuries Tuberculosis Whooping cough Other(s)Please describe your childhood family experience. Include who raised you, how many siblings you have, what were family routines and traditions? etc. Be as descriptive as possible. Is there anything from your childhood that causes you distress today? What support do you have in your life (Family / Friends / School / Work / Social activities, etc)? What is your Education History ( highest grade completed and or highest degree obtained) Have you received psychotherapy or counseling in the past? If yes, when was that? Have you seen a psychiatrist in the past? Have you been diagnosed with any mental health concerns? Is there a history of any of the following in the family? Please tick the boxes that apply and specify relationship to patient: Alzheimer's disease/Dementia Behavior problems Birth defects Cancer Diabetes Emotional problems Heart disease High blood pressure Stroke Thyroid problems Tuberculosis Other chronic or serious health problemsDescribe your current physical health: Good Fair PoorOther InformationWhat is your current financial situation? Check all that apply: No current financial problems Large indebtedness Poverty or below-poverty income Impulsive spending Relationship conflicts over finances OtherWhat are the major causes of your stress? (Marital / Financial / Career / Family / Health / Unfulfilled expectations, etc) Do you have any difficulties with alcohol, drugs or food? If yes, please dissert about such difficulties. As a child, did you experience difficulty with any of the following? You may use the boxes to further specify the behaviors. Check all that apply: Animal cruelty Assault to others Bizarre behavior Breaking things Controlling bladder Disobedience Feeding self Fire-setting Frequently daydreams Frequently tearful Hyperactivity Lack of attachment Often sad Unable to play cooperatively Poor concentration Riding bicycle Self-injurious threats Speaking sentences Speaking words Tolerating separation OtherPlease describe any serious hospitalizations or accidents you went through: Which - if any - of these substances do you currently use or have used in the past? Alcohol Amphetamines Barbiturates/Owners Caffeine Cocaine Crack cocaine Hallucinogens (e.g., LSD) Inhalants (e.g., glue, gas) Marijuana or hashish Nicotine/cigarettes PCP None of the aboveIf any, which have been the consequences of substance abuse in your life? Arrests Assaults Binges Blackouts Hangovers Job loss Loss of control Medical conditions Overdose Relationship conflicts Seizures Sleep disturbance Suicidal impulse Tolerance changes Withdrawal symptoms OtherSubstance usage status: No history of abuse Active abuse Early partial remission Early full remission Sustained partial remission Sustained full remissionIs there a history of alcohol/drug abuse in your family? No-one Father Mother Sibling(s) Grandparent(s) Stepparent (live-in) Uncle(s)/Aunt(s) Spouse/Significant other Children OtherYour habits Please describe, when applicable: Smoking Alcohol Recreational Drugs Coffee Sleeping Pills OtherIf you selected any of the options above, please describe how much you take per day? How is your social interaction? Check all that apply: Normal social interaction Isolates self Very shy Alienates self Inappropriate sex play Dominates others Associates with acting-out peers OtherWhat is your legal situation? Check all that apply: No legal problems Now on parole/probation Arrest(s) not substance- related Arrest(s) substance-related Court ordered this treatment Jail/prison (specify how many times and total time imprisoned) Jail/prison (specify how many times and total time spent) OtherIf other, please specifiy: On average, how many hours a week do you spend Driving/Commuting? On average, how many hours a week do you spend Reading? On average, how many hours a week do you spend watching TV/playing video games? On average, how many hours a week do you spend using the computer? What is your stress level? Low Average Considerable UnbearableHow do you cope with stress? What are your passions and leisure pursuits? Please provide any other information you think will be necessary or helpful: Check to confirm completion of this report to the best of your knowledge.Submit Form
