USM
MC Marinee & Familyy Programss
Intakee Informatiion FOUO
O – PRIVACY SSENSITIVE WH
HEN FILLED IN
N Name:
Date of birth:
Gendeer:
Racial//Ethnic Backgground:
Who reeferred you?
Curren
nt Address:
☐Civilian Housing or ☐Military Ho
ousing Perman
nent Address:
Today’s Daate:
DoDID or SS#: Phone Number 1:
Phone Number 2:
would you like staff to contaact you?
How w
☐ Cell ☐ Hom
me ☐ Work me ☐ Work ☐ Cell ☐ Hom
Is it okkay for staff to
o leave a messaage for you att the numbers above? ☐Yees ☐No Email A
Address (Perssonal):
Em
mail Address (W
Work):
Presen
nting Concern: What b
brings you herre today?
Have yyou sought treatment for thiis before now
w (if yes, when))?
Militarry History (iff applicable)::
Branch
h of service: ☐Marine
☐
Corp
ps ☐Navy ☐Air Forcce ☐Coast Guard ☐D
DOD Agencyy
Duty Status: ☐Actiive ☐Reserrves ☐Spouuse ☐Child
d ☐Familyy Member ☐D
DoD Caregiveer
☐Arm
my ☐Other:
☐Civilian (OCONUS
S) Highesst rank:
If you aare not curren
ntly active dutyy, what prior service
s
do youu have?
h:
Branch
Dates:
T
Type of Dischaarge?
Deployyment/combaat history (locaation/date):
njuries while in
n the military?
Have yyou had any in
1 USMC Marine & Family Programs
Intake Information FOUO – PRIVACY SENSITIVE WHEN FILLED IN Have you ever experienced any head trauma due to an explosion, a blast, a fall, a motor vehicle accident, sports injury or other
incident? ☐ Yes ☐No If Yes, when?
Did you lose consciousness, “see stars,” or have a sense of being dazed, or are you unable to recall the injury? ☐Yes ☐No Did you receive treatment or see a medical professional as a result of the trauma? ☐Yes ☐No If Yes, provide details.
Do you want to be referred to a medical professional for any concerns you might have that you think might be related to a possible
head trauma or concussion? ☐Yes ☐No What other vocational/other training have you received in the military?
If Active Duty (if not active duty, fill this out with sponsor’s information):
Rank:
Command:
Dates of Service:
MOS:
Command/Unit and Command/Unit phone number:
Commander’s/Supervisor’s name and phone number:
Major Command:
Battalion:
Company:
Your EAS date:
Your PCS date:
If Reserves: Location:
Unit Commander:
If not Active Duty: Occupation: _______________________ Employer: _______________________ Sponsor: _____________________
Employment History (if not in the military):
Are you currently employed? ☐Yes ☐No If you were ever terminated from a job, please explain.
Source of Income: (check all that apply) ☐Employment ☐Temporary Assistance for Needy Families/AFDC ☐WIC ☐SSI ☐SSDI ☐Survivor’s Benefits Relationships/Support Systems/Living Arrangements:
Current Status: ☐Married ☐Divorced ☐Separated ☐Widowed ☐Significant Other ☐Domestic Partnership ☐Single How many times have you been married: _______
If currently married, how long? _______
Do you live on base housing? ☐Yes ☐No
Who do you live with and please describe your home life.
☐Do you rent or ☐Own your home? 2 USMC Marine & Family Programs
Intake Information FOUO – PRIVACY SENSITIVE WHEN FILLED IN Do you have any children?
Name
Age
Gender
Date of Birth
Where do they reside
Educational Background and Literacy Level: Highest level of education achieved?
Please explain why if you left high school, vocational school, or college without graduating.
Were you ever diagnosed with learning disabilities? ☐Yes ☐No Please describe any behavioral, learning disabilities, or experiences that are significant to your educational history or learning ability.
Are you interested in furthering your education? ☐Yes ☐No Legal Information: Please list legal proceedings you or your family members are involved with (divorce, military protection order, civil protection
order, civil, criminal, traffic, court martial).
Who
Charges
Which Court
Probation
Upcoming Hearing/Trial Dates
Information
Do you have a history of receiving traffic violations? ☐Speeding ☐DUI ☐DWI ☐Other: Physical Health: Please list any medical conditions or diagnosis you currently have.
Diagnosis
Date
PCM/Doctor Treatment
Location of
Medication
Diagnosed
Received
Treatment
Ever hospitalized for
this condition?
If the medications are not helping/working for you, provide details of which medications and your response to them.
Please list which medications you are allergic to and the reaction you have to them.
Are you being seen by any other agency? ☐Naval Health ☐DSS ☐Chaplain ☐MFLC
☐Other: _______________________________________
☐Military OneSource
HQMC Ver-2 Implemented: Aug 2014; Rev: Sept 2014 (Added DoDID or SS# and Customer Rights Acknowledgement); Rev 4 May 2015 to add
Physical Health
3 Client’s Name:
Case Number:
Health and Wellness Assessment
On a scale of 1 to 10, 1 being the least and 10 being the most:
*Overall level of disturbance, dissatisfaction you are feeling in your life currently: ________
*Overall level of satisfaction / happiness you are feeling in your life currently: _________
1. Rate your physical health: Excellent
Good
Average
Declining
Other
If other, explain:_________ ______________________________________________
2. Are you presently taking medications? Yes
No
If yes,
What? ____________________ _________________________ ______________________
Prescribed by? ______________________________
3. Have you ever received any therapy or counseling before? Yes
No
If yes, for what? When?: ________________________________________________
4. In the past 30 days have you noticed any of the following: (check all that apply)
excessive sadness
crying episodes
hopelessness
difficulty concentrating
weight loss
weight gain
loss of appetite
overeating
difficulty in social situations
difficulty making decisions
recurring thoughts of death
easily frustrated/impatience
irritability
sleep problems
memory problems
thoughts of suicide
withdrawing from others
difficulty functioning at work
nausea/vomiting
low energy/fatigue
reduced interest/pleasure
feelings of worthlessness/guilt
agitation
restlessness
excessive worry
fearfulness
trembling/shaking
shortness of breath
fear of loss of control
feeling detached from others/life
intrusive thoughts of bad memories
panic attacks
fear of leaving home
avoidance of public places
avoidance of social situations
pounding heart/palpitations
chest pain
nightmares
flashbacks/re-living bad experiences
easily startled/upset
*********************************************************************************************************************
5. Is there a family history of mental illness? Yes
No
6. Have you ever been diagnosed with a mental illness? Yes
No
If yes,
explain: _______________________________________________________________
7. Have you ever had a head injury or seizures or been treated for neurological problems?
No
If yes, explain:________________________________________________
Yes
Client’s Name:
Case Number:
8. Do you have any concerns about your mental or emotional well-being?
Yes
No
If yes, explain: ________________________________________________
9. Have you ever thought about hurting yourself or others? Yes
No
If yes,
When? __________ How? ___________ Explain: _______________________________
_________________________________________________________________________
10. Do you now or have you in the past few weeks, felt like hurting yourself or others?
Yes
No
If yes, explain: ______________________________________________
11. Have your ever engaged in self injurious behaviors (i.e., cutting, burning, piercing,
hair pulling, skin picking, etc…) Yes
No
If yes, explain: _________________________________________________________
12. Have you ever been in a relationship/marriage that was violent? Yes
No
If yes, explain: ___________________________________________________________
13. Have there been any incidents of violence in this marriage? Yes
No
If yes, explain: ___________________________________________________________
14. How often do you drink alcohol? Never
Rarely
When you drink do you drink to get drunk? Yes
Occasionally
No
Often
15. Have you been treated for alcohol and/or drug abuse within past three years?
Yes
No
Type of treatment: __________ When: __________ Length: _____
Did you complete the program? Yes
No
Why not? ______________________
16. Have the civilian or military authorities been to your house in the past two years?
No
If yes, explain:_______________________________________________
Yes
_________________________________________________________________________
No
17. Have you been deployed to a combat area? Yes
If yes, when and where? ____________________________________________________
18. Have you ever experienced a traumatic event? Yes
No
19. What is your main concern as you see it?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
20. What have you done about it?
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________
Rev. 6/14