Preparing For Your Interview

Preparing for your interview with Dr. Simpson

Please fill out the following information and bring the completed form to your appointment. The form takes some time to fill out, but the information you provide is essential. Please be as truthful and complete as possible.

Step 1 of 9

Your Name:*
Date of Birth:*
MM slash DD slash YYYY
Current Age:
Today’s Date:
MM slash DD slash YYYY
Height:
Weight:
Ethnic Background :
Eye Color:
Hair Color:
CHILDHOOD
Where were you born and raised:
Who helped raise you:
If your parents ever divorced, how old were you when this happened?
Briefly describe your father (his personality , work, did he have problems with alcohol, drugs or mental health?
Briefly describe your mother: (her personality, work, did she have problems with alcohol, drugs or mental health?)
If you were raised by a stepparent, grandparent, a parent’s boyfriend/girlfriend, foster parent or other, please describe them:
Please give the ages and brief description of your siblings, step – siblings or half – siblings. Do they have any problems with alcohol, drugs, or mental health?
In general, how would you describe your childhood growing up:
Have you ever been a member of a gang or hung out with gang members?
YOUR EDUCATION
In general, how was grade school? What were your grades like?
In general, how was middle school? What were your grades like?
In general, how was high school? What were your gr ades like?
Did you repeat any grades ?
Were you diagnosed ADD or ADHD?
Did you have Special Ed classes? If “ yes ”, what academic problems did you have?
Were you ever suspended or expelled? If “ yes ” – describe what happened:
High School Diploma:
High School Diploma:
- Yes
- No
High School G.E.D.:
- Yes
- No
College classes?
College Degree ?
YOUR MOST RECENT EMPLOYMENT
Employed by:
Job description :
How long?
PAST EMPLOYMENT:
Beginning with your first job, list . . .
Job title:
Reason this job ended:
How long employed:
Job title:
Reason this job ended:
How long employed:
Job title:
Reason this job ended:
How long employed:
Job title:
Reason this job ended:
How long employed:
Job title:
Reason this job ended:
How long employed:
Did you ever serve in the military?
Are you on Social Security Disability?

EMOTIONAL HEALTH
If you have ever met with a counsel or, please describe
(even as a child)
1st Counselor :
When:
MM slash DD slash YYYY
Why:
How:
2nd Counselor :
When:
MM slash DD slash YYYY
Why:
How:
3rd Counselor :
When:
MM slash DD slash YYYY
Why:
How:
4th Counselor :
When:
MM slash DD slash YYYY
Why:
How:
5th Counselor :
When:
MM slash DD slash YYYY
Why:
How:
If you ever been admitted to a psychiatric hospital , please describe each time
For the 1st hospitalization:
When:
MM slash DD slash YYYY
Why:
How:
For the 2nd hospitalization:
When:
MM slash DD slash YYYY
Why:
How:
For the 3rd hospitalization:
When:
MM slash DD slash YYYY
Why:
How:
For the 4th hospitalization:
When:
MM slash DD slash YYYY
Why:
How:
For the 5th hospitalization:
When:
MM slash DD slash YYYY
Why:
Became very anxious, nervous, and tense.
- Never
- Not much
- In the middle
- Frequent/lots
How:
If you ever tried to kill yourself, please describe each time:
1st Suicide Attempt
When:
MM slash DD slash YYYY
Why:
How:
2nd Suicide Attempt
When:
MM slash DD slash YYYY
Why:
How:
3rd Suicide Attempt
When:
MM slash DD slash YYYY
Why:
How:
4th Suicide Attempt
When:
MM slash DD slash YYYY
Why:
How:
5th Suicide Attempt
When:
MM slash DD slash YYYY
Why:
How:
Have you had recent though ts of killing yourself?
- Yes
- No

Preparing For Your Interview

Preparing for your interview with Dr. Simpson

Step 1 of 9

CHILDHOOD

YOUR EDUCATION

High School Diploma:

YOUR MOST RECENT EMPLOYMENT

PAST EMPLOYMENT:

RESIDENCE

PAST L ONG – TERM RELATIONSHIPS OR MARRIAGES :

LEGAL ASSESSMENT

YOUR SPIRITUAL ORIENTATION

OTHER INFORMATION

YOUR PHYSICAL HEALTH

List any current medications below:

Alcohol and other Drug Use

Number of times in your lifetime

Effects from Drinking and Drugging

EMOTIONAL HEALTH

1st Counselor :

2nd Counselor :

3rd Counselor :

4th Counselor :

5th Counselor :

If you ever been admitted to a psychiatric hospital , please describe each time

For the 1st hospitalization:

For the 2nd hospitalization:

For the 3rd hospitalization:

For the 4th hospitalization:

For the 5th hospitalization:

If you ever tried to kill yourself, please describe each time:

1st Suicide Attempt

2nd Suicide Attempt

3rd Suicide Attempt

4th Suicide Attempt

5th Suicide Attempt

Feelings of Depression

Check the box to the right that best describes how much a symptom or problem has bothered you during the past two weeks .

Feelings of Anxiety

Check the box to the right that best describes how much a symptom or problem has bothe red you during the past two weeks .

Unpleasant Thoughts or Experiences

Threats t o Your Life