STEVE FRANKLIN, M.S.W., L.C.S.W.

6829 Gravois Ave.                                                                                                                                      314-517-8383

St. Louis, MO  63116                                                                                                               SteveFranklin@JUNO.com     

 Name __________________________________________     Date: ______________

Social Security #_____________________ Insurance/ ID#  _______________________

How did you learn about my services? _________________________________

Is there any other agency, individual or organization involved in your case who you might want me to contact? (explain)

 


                                                                                                                                                                                               

(If you want me to discuss your case with anyone else, ask for an "Authorization to Release Information")

Services Needed: o Individual                       oFamily                     oCouples/Marital

WHO LIVES IN YOUR HOUSEHOLD?

 

 


Name

 


                                   SELF           

Relationship

 


Race/Sex

 


Age

 


D.O.B.

Psychiatric

Diagnosis

 


Employer/School

Last Grade Compl.

 


# of Marriages

 

HAVE YOU OR ANY FAMILY MEMBER EVER HAD ISSUES WITH....

                                                                No           Yes         Who                       Where/What                         When

Psychiatric Hospitalization?               o          o          ___________________________________________

Suicide Attempt?                                 o          o          ___________________________________________

Alcohol/Drug Usage?                         o          o          ___________________________________________

(Alcohol drug usage in past 30 days): _______________________________________________________

Sexual/Physical Abuse?                     o          o          ___________________________________________

Family Mental Illness history?          o          o          ___________________________________________

 

Personal  strengths ______________________________________________________________________________

___________________________________________________________________

Social Supports__________________________________________________________

Other Comments:  ______________________________________________________________________________

 

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