The Counseling Center Of New England

One Main Street * Nashua, NH 03064 * (603) 883-0005
8 Auburn Street * Nashua, NH 03064 * (603) 883-0005
15 Trafalgar Square * Nashua, NH 03063 * (603-883-0005                                 
148 Coolidge Avenue * Manchester, NH  03102 * (603) 627-3111
294 D.W. Highway * Merrimack, NH  03054 * (603) 883-0005
77 Gilcreast Rd * Suite 3000 * Londonderry, NH  03053 * (603) 432-3033
45 Main Street * Peterborough, NH  03458 * (603) 924-3331
414 State Street * Unit 2 * Portsmouth, NH  03801 * (603) 334-2533
24 Front Street * Suite 100 * Exeter, NH 03833 * (603) 778-2005  
16 Lincoln Street * Suite C * Brunswick, ME 04011 * (207) 406-4222
53 Baxter Boulevard * Portland, ME 04103 * (603) 883-0005
61 NH Route 27, Unit 10 * Raymond, NH 03077 * (603) 689-7602
319 Whittier Highway * Suite 8 * Center Harbor, NH 03326 * (603) 546-6178 
Fax all locations: 603-883-0007

ADULT CLINICAL HISTORY FORM

PRIVACY NOTE:  This form meets HIPAA guidelines for privacy and secure electronic transmission.  Please note the lock on the bottom right corner of your web browser ensures your privacy, and all information is encrypted during transmission once completed.  Only administrative staff trained in HIPAA privacy rules and confidentiality will handle the print out of this document for delivery to your medical record prior and your provider.  Completion of this form will substantially expedite the information gathering process for your first appointment, and allow your provider to focus more specifically on the issues that require attention by avoiding additional spent on general background and medical information. Your cooperation is appreciated.

~~ Please Note:  Only complete this form if you have spoken to our Intake Department and have already scheduled your first appointment. If you have not, please complete the Request Appointment Form for an Adult or Child/Teen ~~

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What problems are leading you to seek help now?

CURRENT SYMPTOMS

Current Symptoms *
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HISTORY OF PRESENTING PROBLEM


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PSYCHIATRIC HISTORY


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Please indicate if you currently consume or did consume in the past any of the substances listed below: *
 
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Substance Use Treatment History

SOCIAL HISTORY


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Do you


MEDICAL HISTORY







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OB/GYN HISTORY (IF APPLICABLE):
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Are you pregnant currently or trying to become pregnant?
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Please indicate if you have had any of the following:
 
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Please indicate if you have had any of the following tests completed in the past:

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Please complete only if your appointment is for an Psychiatrist (M.D) or Advanced Registered Nurse Practitioner (ARNP). If your appointment is with a psychologist or counselor, please omit.

Pharmacy Preferences:

~~ Please Note:  Only complete this form if you have spoken to our Intake Department and have already scheduled your first appointment. If you have not, please complete the Request Appointment Form for an Adult or Child/Teen ~~