Cornerstone Counseling Foundation

Client Information Form 来访信息表

Cornerstone 主要为亚洲的禾场工人，志愿者和泰国本地同工提供服务，通过从信仰与专业角度出发的保密专业的咨询和培训，服务对象包括个人、婚姻、家庭、团队和组织。

身份信息

IDENTIFICATION

姓名Z: Name*

姓氏)

名字

年龄：Age*

性别：Gender*

护照国家：Passport Country*

电话号码: Phone Number*

电子邮件：Email*

Current job 现职工作(选项) Cross culture field worker 跨文化工人Local field worker 本地同工Other 其他

Please type another option here:

有当前婚姻状况（请选择所有适用项）Current Marital Status * SingleMarriedDivorcedRemarriedOther 其他

Please type another option here:

有孩子吗？*： Children?* 是Yes否no 如果有，请具体说明姓名、性别和年龄

If Yes, specify name(s), gender(s), and age(s)

个人咨询经历

Personal Counseling Experience

列出任何之前的咨询经历及日期，包括非专业咨询、牧者咨询、会员关怀等。如果没有，请注明 n/a。*List any prior counseling and dates, including lay counseling, pastoral, member care, etc. In none, indicate n/a. * 列出任何之前的住院或住院精神健康治疗及日期。如果没有，请注明 n/a。List any prior inpatient or residential mental health treatment and dates. If none, indicate n/a. * 您希望在咨询中解决哪些问题或顾虑?： What concerns or issues do you wish to address in counseling?* 您希望在 Cornerstone 咨询中取得什么成果？What do you hope to accomplish at Cornerstone Counseling?* 请列出任何您希望咨询师知道的额外人际、环境或精神上的顾虑： Please list any additional interpersonal, environmental, or spiritual concerns that you would like your counselor to know* 您请求的咨询形式（请选择所有适用项) ： Which form(s) of counseling are you requesting? (check all that apply)* 婚姻咨询 Marital Counseling个人咨询 Individual Counseling家庭咨询 Family Counseling子女教育 Parent Consultation精神科医生咨询 Psychiatric Consult个人总结回顾 Individual Debriefing (1-2 sessions)家庭总结回顾 Marital Debriefing (1-2 sessions)婚姻总结回顾 Family Debriefing (1-2 sessions) 如果选择多个，请列出您的咨询优先顺序。例如：1- 婚姻咨询，2- 个人咨询等。 List your counseling priority order for multiple selections.

在我们安排咨询师时请问你是否有其他特殊需求（如语言，性别等？ Are there any additional comments or preferences that you think are important for us to know in order to find a good fit for you in a counselor?

您什么时候有空？ When are you available?*

这些日期/时间灵活吗？Are these dates/times flexible?* 是Yes否no 请注明是否有其他可行性的时间。请注意，我们优先考虑与客户面对面会面的请求。Indicate any additional comments about your availability. Please note that we are prioritizing requests to meet with clients in person.

您的咨询是自愿的还是强制的?： Is your counseling voluntary or mandatory?* Voluntarymandatory 这些日期/时间灵活吗. If a report is required, indicate name and email.

个人身体健康历史

Personal Physical Health History

体重变化？ Changes in weight?*

	是 yes	否 no
体重增加? Signs of weight gain?	Yes	No
体重减少? Signs of weight loss?	Yes	No

最后一次体检：(日期/年份) Last Complete Physical Exam*

(MM/YY)

医院： Hospital*

列出您或医生所知的任何过去或现在的医疗问题。如果没有，请注明 n/a。List any past or present medical problems that doctors or you are aware of. If none, indicate n/a. * 列出您认为重要的手术和住院经历。如果没有，请注明 n/a。 List surgeries and hospitalizations that you believe are important for us to know. If none, indicate n/a.* 列出您目前服用的处方药和非处方药，包括避孕药、维生素、草药、吸入剂等。请包括剂量和服用时间。如果没有，请注明 n/a。 List prescribed & over-the-counter drugs you currently take, including birth control, vitamins, herbal remedies, inhalers, etc. Please also include dosage and time of day taken. If none, indicate n/a. * 列出对任何药物的过敏或不良反应。如果没有，请注明 n/a。 List allergies or adverse reactions to any medication. If none, indicate n/a. * 列出您曾尝试过的任何精神药物（如抗抑郁药、抗焦虑药、情绪稳定剂、ADHD药物或安眠药），并尽可能提供剂量。如果没有，请注明 n/a。 List any past psychotropic medications you have tried (and doses, if possible), such as antidepressants, anti-anxiety medications, mood stabilizers, ADHD medications, or sleep aids. If none, indicate n/a. *

睡眠模式

Sleep Pattern

平均每晚睡眠小时数： Average number of hours of sleep per night* 描述您的睡眠模式的任何变化。如果没有，请注明 n/a。 Describe any changes in your sleep patterns. If none, indicate n/a.*

定期使用安眠药吗？ I regularly use sleeping medication.* 是Yes否no

个人心理健康历史

Personal Mental Health History

请勾选适用项：(请提供具体情况。如果没有，请注明 n/a。) Check any that apply. 物质/药物滥用 Substance/medication misuse童年时期的忽视或伤害 Childhood neglect or harm自杀未遂 Suicide Attempt父母的愤怒 parental anger有心理健康问题的父母/兄弟姐妹 Parent/siblings with mental health issues强迫性性行为 Compulsive sexual behavior非自杀性自残 non-suicidal self harm暴饮暴食,限制饮食,催吐 overeating, restricting, vomiting父母离异 Parents divorced家庭成员或亲近的人自杀 suicide of a family member or someone close焦虑 Anxiety暴力受害者 Victim of Violence沮丧 Depression慢性健康问题/残疾 Chronic health problems/ disability家庭成员死亡 death of family member多起人身意外 Multiple accidents性虐待/性侵犯 sexual abuse有自杀念头 Suicidal thoughts虐待关系 abusive relationship父母酗酒或吸毒 Parent that is alcoholic or drug addict学习障碍 learning disability其他: Other

Please type another option here

解释已勾选的项目。如果没有，请注明 n/a.Explain checked items. If none, indicate n/a.* * 列出您血亲中的任何心理或情绪问题，包括症状、诊断和您所知道的药物。如果没有，请注明 n/a。 List any mental or emotional problems in any of your blood relatives. Include symptoms, diagnosis and medication that you are aware of. If none, indicate n/a.* *

症状检查表

Symptoms Checklist

说明：以下问题询问可能困扰您的事情。在过去的两（2）周内，请圈出最能描述您受到每些问题困扰程度的数字。空格中打勾。 Instructions: The questions below ask about things that might have bothered you. For each questions, circle the number that best describes how much (or how often) you have been bothered by each probem during the past TWO (2) WEEKS. I*

	(0) 完全没有 None	(1) 轻微 - 稀有 , 少于一到两天 Slight	(2) 中等 - 几天 Mild	(3) 中等 - 超过一半的天数 Moderate	(4) 严重 - 接近每天 Severe-
1. 对做事情没有兴趣或乐趣 ? Little interest or pleasure in doing things ?	0	1	2	3	4
2. 感到沮丧、抑郁或绝望吗 ? Feeling down , depressed , or hopeless ?	0	1	2	3	4

II*

	(0) 完全没有 None	(1) 轻微 - 稀有 , 少于一到两天 Slight	(2) 中等 - 几天 Mild	(3) 中等 - 超过一半的天数 Moderate	(4) 严重 - 接近每天 Severe-
3. 感到比平时更易怒、更烦躁或生气吗？ Feeling more irritated, grouchy, or angry than usual?	0	1	2	3	4

III*

	(0) 完全没有 None	(1) 轻微 - 稀有 , 少于一到两天 Slight	(2) 中等 - 几天 Mild	(3) 中等 - 超过一半的天数 Moderate	(4) 严重 - 接近每天 Severe-
4.睡眠少于平时，但仍然有很多精力？Sleeping less than usual, but still have a lot of energy?	0	1	2	3	4
5.开始做比平时更多的项目，或者做更多冒险的事情？ Starting lots more projects than usual or doing more risky things than usual?	0	1	2	3	4

IV*

	(1) 轻微 - 稀有 , 少于一到两天 Slight	(2) 中等 - 几天 Mild	(3) 中等 - 超过一半的天数 Moderate	(4) 严重 - 接近每天 Severe-
6. 感到紧张、焦虑、害怕、担忧或神经紧绷吗？ Feeling nervous, anxious, frightened, worried, or on edge?	1	2	3	4
7. 感到恐慌或害怕吗？ Feeling panic or being frightened?	1	2	3	4
8.避免让你感到焦虑的情况？ Avoiding situations that make you anxious?	1	2	3	4

	(0) 完全没有 None	(1) 轻微 - 稀有 , 少于一到两天 Slight	(2) 中等 - 几天 Mild	(3) 中等 - 超过一半的天数 Moderate	(4) 严重 - 接近每天 Severe-
9. 无明显原因的疼痛和不适（例如：头痛、背痛、关节痛、腹痛、腿部不适）？ Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)?	0	1	2	3	4
10感到你的疾病没有得到足够重视？ Feeling that your illnesses are not being taken seriously enough?	0	1	2	3	4

VI*

	(0) 完全没有 None	(1) 轻微 - 稀有 , 少于一到两天 Slight	(2) 中等 - 几天 Mild	(3) 中等 - 超过一半的天数 Moderate	(4) 严重 - 接近每天 Severe-
11有伤害自己的想法吗？ Thoughts of hurting yourself?	0	1	2	3	4

VII*

	(0) 完全没有 None	(1) 轻微 - 稀有 , 少于一到两天 Slight	(2) 中等 - 几天 Mild	(3) 中等 - 超过一半的天数 Moderate	(4) 严重 - 接近每天 Severe-
12. 听到其他人听不到的声音，比如即使周围没有人也能听到的声音吗？ Hearing things other people couldn’t hear, such as voices even when no one was around?	0	1	2	3	4
13. 感到有人能够听到你的想法，或者你能够听到另一个人的想法吗？ Feeling that someone could hear your thoughts, or that you could hear what another person was thinking?	0	1	2	3	4

VIII*

	(0) 完全没有 None	(1) 轻微 - 稀有 , 少于一到两天 Slight	(2) 中等 - 几天 Mild	(3) 中等 - 超过一半的天数 Moderate	(4) 严重 - 接近每天 Severe-
14. 整体睡眠质量是否有受到严重影响？Problems with sleep that affected your sleep quality over all?	0	1	2	3	4

IX*

	(0) 完全没有 None	(1) 轻微 - 稀有 , 少于一到两天 Slight	(2) 中等 - 几天 Mild	(3) 中等 - 超过一半的天数 Moderate	(4) 严重 - 接近每天 Severe-
15. 是否有记忆问题（例如，学习新信息）或定位问题（例如，找不到回家的路）吗？ Problems with memory (e.g., learning new information) or with location (e.g., finding your way home)?	0	1	2	3	4

	(0) 完全没有 None	(1) 轻微 - 稀有 , 少于一到两天 Slight	(2) 中等 - 几天 Mild	(3) 中等 - 超过一半的天数 Moderate	(4) 严重 - 接近每天 Severe-
16. 反复出现在你脑海中的不愉快想法、冲动或画面? Unpleasant thoughts, urges, or images that repeatedly enter your mind?	0	1	2	3	4
17. 感到被迫反复执行某些行为或心理活动？Feeling driven to perform certain behaviors or mental acts over and over again?	0	1	2	3	4

XI*

	(0) 完全没有 None	(1) 轻微 - 稀有 , 少于一到两天 Slight	(2) 中等 - 几天 Mild	(3) 中等 - 超过一半的天数 Moderate	(4) 严重 - 接近每天 Severe-
18. 有感到与自己、身体、周围环境或记忆脱离或疏远感吗？ Feeling detached or distant from yourself, your body, your physical surroundings, or your memories?	0	1	2	3	4

XII*

	(0) 完全没有 None	(1) 轻微 - 稀有 , 少于一到两天 Slight	(2) 中等 - 几天 Mild	(3) 中等 - 超过一半的天数 Moderate	(4) 严重 - 接近每天 Severe-
19. 不知道自己真正是谁或想要什么样的生活？ Not knowing who you really are or what you want out of life?	0	1	2	3	4
20与他人没有亲近感或不享受与他人之间的关系？ Not feeling close to other people or enjoying your relationships with them?	0	1	2	3	4

XIII*

	(1) 轻微 - 稀有 , 少于一到两天 Slight	(2) 中等 - 几天 Mild	(3) 中等 - 超过一半的天数 Moderate	(4) 严重 - 接近每天 Severe-
21. 在一天内饮用至少 4 杯任何类型的酒精饮料？ Drinking at least 4 drinks of any kind of alcohol in a single day?	1	2	3	4
22. 吸烟（香烟、雪茄或烟斗），或者使用鼻烟或嚼烟吗？ Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco?	1	2	3	4
23. 自行使用以下任何药物，即没有医生处方，以超过规定剂量或时间的方式使用：[例如，止痛药（如维柯丁）、兴奋剂（如利他林或阿莫达非尼）、镇静剂或安眠药（如安眠药或安定）、或大麻、可卡因或冰毒、派对药物（如摇头丸）、迷幻药（如LSD）、海洛因、吸入剂或溶剂（如胶水）或甲基苯丙胺（如速效药）]? Using any of the following medicines ON YOUR OWN, that is, without a doctor’s prescription, in greater amounts or longer than prescribed.	1	2	3	4

注：如果有任何相关的心理或心理教育评估的书面报告，请一并发送给咨询师。
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