Psychology Clinic

1611 W. Mulberry
Denton, TX 76203
(940) 565-2631
Fax: (940) 369-8672

A dult History Form

Date: _______October 8, 2018_____________

Name:
__________Shi________________________Melanie___________________________
________
Last First Middle

Date of Birth: _____01-03-1998___________ Age:___20____ Gender:

_______female__________

Address:

___3617 Pearl Lane_____________Flower Mound____TX______75022____________

Number & Street City State Zip

Phone: (Home) _____none______ Can a message be left? __ Yes __ No

(Cell) _______9402304457___ Can a message be left? __ Yes _x_ No

PEOPLE CURRENTLY IN HOUSEHOLD INCLUDING YOURSELF

_____________________________________________________________________
Name Relationship Age Gender Educational Occupation
to Client____ ___ Level___________________

1._ Melanie Shi___self________20_____fem________college____ ____student____

2._Mary Zhong____mom_______55______fem______masters___financial analyst__

3.__Jack Shi_______dad_______56_______male_____ masters ___database admin

4.____________________________________________________________________

UNT Psychology Clinic Adult Form, page 1

Current Concerns

Please describe the reasons why you would like to participate in the Relationship
Therapy Group. Identify the relationship concerns, problems, or issues that you would
like to discuss, and possibly resolve, as a result of your participation.

I struggle with codependent behavioral patterns with my mother, to whom I have an

insecure attachment. I want help and more advice setting healthy boundaries between
me and my parents, knowing what they can and can’t do for me, being independent
while connected. My parents often do or say things that invalidate my emotions and
experiences, and I want to work on self-validation and other tools I can use to be more
resilient when this happens. I’m also currently in a state when I’m still blaming my
mother more than forgiving her - I want to find a way to build a healthy, functional, living
adult-adult relationship with her that can be rewarding for the both of us.

Current Life Circumstances

Is there anything that has recently happened or is about to happen that represents a
major change in your life?
Recently happened - I went on medical leave from my primary university in New York in
Feb. 2018 to come home and work on some of these issues with my parents. Major
upcoming change - will move back to New York to finish undergraduate degree.

Is there anything else that your therapist should know about you or your current life
circumstances?

Being on medical leave from my original university and recently enrolling at UNT means
that I am new to the campus environment/community, so I lack in person support here.
Most of my close friends are still around my school in New York.

Check any of the following that accurately describe you or your current life
circumstances:

_______ overwhelmed _______ sleep difficulties

___x__ unhealthy eating - occasional
_______ excessive caffeine intake
_______ problems at work
_______ suicidal thoughts
___x___ low self-esteem
_______ excessive drug use
_______ self-injurious behavior
_______ health problems
_______ depression
___x___ feeling empty
_______ recent traumatic event (what kind?)_________________________________
_______ excessive alcohol use
_______ inadequate exercise
___x___ lonely
_______ abused
_______ hopeless
___x___ anxiety
_______ spiritual concerns
_______ financial problems
_______ problems with temper
_______ victim of violence

UNT Psychology Clinic Adult Form, page 2

Marital Information

Current Marital Status: _x Single (never married) __ Married __ Separated

__ Divorced __ Living with committed Partner __ Widowed

Name of Spouse/Significant Other: ___Hayden________________________

Length of Marriage/Relationship: _____not married, but we have been in a romantic

relationship for ~ 1 month______________________________

If you are married or involved in an intimate/romantic relationship, which of the following

terms best describe your relationship? (Check all that apply):

__x__ happy ___x___ balanced

______ distant _______ intolerable
______ sexually satisfying _x - can be______ tense
__x___ safe _______ disappointing
______ predictable _______ partner too dependent on you
______ unstable __x - I fear this_ you too dependent on partner
__x___ partner supportive of you __x____ affectionate
__x___ you supportive of partner __x - I hope____ secure
__x___ trusting

Check any of the following that are sources of conflict or concern in your relationship:

__x___ parenting style _______ parenting responsibilities

_______ politics
__x___ communication
__x____ finances
_______ mutual interests
_______ work loads
_______ sharing housework
__x____ your problems
_______ religion
_______ lack of mutual caring
__x____ sexuality
_______ sharing resources
_______ partner’s alcohol or drug use
_______ your alcohol or drug use
_______ partner's problems

Current relationship with parent figures:

Mother: __ Excellent __ Good _x_ Fair __ Poor __ No Contact

__ Parent Deceased
Father: __ Excellent _x_ Good __ Fair __ Poor __ No Contact
__ Parent Deceased
Other: __ Excellent _x_ Good __ Fair __ Poor __ No Contact
__ Parent Deceased

Is there anything else important for your therapist to know about your family or important
relationships? :

UNT Psychology Clinic Adult Form, page 3

My parents immigrated from China - so part of our difficulties are cross-cultural in
nature. Culturally sensitive therapy would be very useful to me.

Employment History

Are you currently employed? _x__ Yes ____ No Hours/week

____10_______

If Yes, where? ______dallas contemporary__________________________ How

Long? ____2 months_______

Work Performance: ___ Excellent _x__ Good ___ Fair ___ Poor

Job Satisfaction: ___ Excellent ___ Good _x__ Fair ___ Poor

Medical History

Self-Assessment of Health: ___ Excellent ___ Good _x__ Fair ___ Poor

Any head injuries? ___ Yes _x__ No

If yes, please explain: _________________ _________________________

_______________________________________________________ ___________

Was it a closed head injury? ___ Yes ___ No

Was it an open head injury? ___ Yes ___ No
Were you hospitalized? ___ Yes ___ No
Did you receive follow-up care? ___ Yes ___ No
Were you unconscious? ___ Yes ___ No
Did you experience memory loss? ___ Yes ___ No

Did you experience any further complications? ___ Yes ___ No

If yes, please describe complications: _________ ________

_________________ _________________ ________

Sleep difficulties? __x_ Yes ___ No

If yes, please describe difficulties: sometimes have difficulty sleeping due

to anxiety manifested as tingling in the bottom half of my legs - especially when I
am sleeping over at my partner’s place or in an unfamiliar environment.

Any additional medical information that may be important that was not asked about:

UNT Psychology Clinic Adult Form, page 4

______struggled on and off with binge eating disorder ____ ______

Mental Health History

Have you ever received counseling/therapy before? _x_ Yes ___ No

If yes, when and for what problem received DBT counseling off & on since May
2018, for binge eating disorder / adjustment disorder

Psychiatric Hospitalizations _x_ Yes ___ No

For what problem? ______past suicidal ideation ____________

Past Suicidal Ideation _x__ Yes ___ No

Past Suicidal Attempt ___ Yes _x__ No
Past Homicidal Ideation ___ Yes _x__ No
Current Suicidal Ideation ___ Yes _x__ No
Current Homicidal Ideation ___ Yes _x__ No

Substance Abuse History

Have you ever had problems with substance abuse (alcohol or drugs)? That is, you
were drinking or using to the point that it created problems for you or anyone else?

___ Yes _x__ No

Have you ever felt you should cut down on your use? ___ Yes ___ No
Have people annoyed you by criticizing your use? ___ Yes ___ No
Have you ever felt bad or guilty about your use? ___ Yes ___ No
Have you ever used drugs or alcohol first thing in the morning to
steady your nerves to get rid of a hangover? (Eye-opener) ___ Yes ___ No

Check any that apply:

___ Alcohol _x__ Tobacco __x_ Caffeine ___ Marijuana
___ Other: _______ _______

Military Service History

Any military service? ___ Yes __x_ No Which branch: __________________

Dates of service: _________________ Type of discharge: _______________

UNT Psychology Clinic Adult Form, page 5

 Any combat-related service? : ___ Yes ___ No

If yes, please describe: ____________ __________________________

________________________________________________________ __________

Culture/Ethnicity

How do you identify yourself racially/ethnically? (Please check all that apply.)

___ African American/ Black ___ South Asian

___ American Indian/Alaskan Native ___ Middle Eastern
___ Anglo/ European American/ White ___ Native African
_x__ Asian/Pacific Islander ___ Central or South American
___ Hispanic/Latino/a ___ Other (please list): __ _ _

Spirituality

What role does spirituality play in your life? I don’t believe in any organized religion, but
I am a spiritual person. I believe in more of a nebulous “life force” like the Daoist chi that
runs through the world. I believe I access a sense of spirituality through intellection and
creative expression.

Do you claim a specific religion? _____no______ If so, which one?

_________________

How often do you attend religious services? __ never

_

Is your religion or your expression of spirituality similar to what was practiced or

expressed in your family of origin?

___ Yes __ No

If no, please describe: ____________ __________________________

__________________________________________ ________________________

How long have you been practicing this religion or expressing your spirituality in this
manner?
_____________ __

Form completed by: Melanie Shi

If not completed by client, what is your relationship to client: ____________________

UNT Psychology Clinic Adult Form, page 6

Thank you for completing this form. We appreciate your cooperation and we will
do our best to provide you with the professional services most appropriate for
you. If you have any questions or additional information, please share them with
your group leader during the screening.

UNT Psychology Clinic Adult Form, page 7