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Jean Kellett, LCSW
9812 Shelbyville Road – Suite 4
Louisville, Kentucky 40223
(502) 423-0509

Client's Personal and Family History

Name, age, current address, educational history, cause and date of death (if applicable), of parents, brothers, sisters, spouse or live-in companion, children and significant others:

Your educational background:

Your work history (include current job):

If married, when? If divorced or separated, when? Please list other marriages, divorces, separations, or annulments.

How much has your family influenced your plans and ambitions?

Somewhat (  )      A little (  )      Not at all (   )

How different is your present household from the family in which you grew up?

Circle three of the listed adjectives that best describe the family in which you grew up:

strict, supportive, affectionate, distant, warm, helpful, silent

Circle three of the listed adjectives that best describe your current household?

strict, supportive, affectionate, distant, warm, helpful, silent

Who are the family leaders?

Do you seek help from:  others outside the family (friends, teachers ministers, etc.)?

In your family, do you have a greater tendency to discuss facts or feelings?

If angry feelings are discussed most often are tender feelings also shared?

Do your disagreements get resolved?

Do you feel about the results?

Do the people in your family expected to do something when you are upset?

Can your family work as a team to plan vacations, family outings, menus, etc.?

Please note any drug or alcohol use by yourself or members of your family. State if you or family members have received treatment for these problems.

Have you been in therapy before? Please state for what reason and with whom.

Has there been or is there now a member of your family in treatment for emotional problems? If yes, please state for what reason and with whom?

Do you or any of your family have learning or physical problems that affect attentiveness or ability to learn in school? If yes, please describe.

Have you had any serious illnesses or accidents? If yes, please describe.

Do you have nightmares? How often?

Have you ever been sexually molested, abused or raped? If yes, when and by whom?

Has anyone in your family been sexually molested, abused or raped? If yes, when and by whom?

Are you concerned about the sexual practices of anyone else in your family?  If the answer is yes, please explain.

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Are you afraid of someone in your family?  If the answer is yes, please explain.

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Are you afraid of anyone else?  If yes, please explain.

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Have you ever thought about or made a suicide attempt?

Has anyone in your family attempted or succeeded at. suicide?

Do you feel there is no point in planning for the future?

Have you or a member of your family shown a major change in behavior within the last year? If yes, please explain.

Do you ever go on eating, drinking, spending, or gambling binges and/or any other kind of behavior that you would consider out of your control? If yes, please explain.

Do you ever make yourself vomit or take laxatives to control your weight?

Do you find yourself refusing to eat or take care of your medical problems to punish members of your family or yourself?

If you have any wish, what is it?

Payment Policy:

Payment is due at the time service is rendered unless other arrangements have been made.

Insurance Coverage:

If you have insurance coverage, you are still responsible for payment in full. We are willing to file your insurance forms and assist you in whatever paper work is necessary.

Appointment Times:

Therapy sessions are tailored to your needs. Most sessions are 50 minutes; however, there are times when a 90-minute or a 120-minute session is planned. Some family sessions may be planned for a 4 to 5 hour segment of time. Any consideration to vary the 50-minute session will be discussed with you to ensure you will be comfortable before any change is made.

Phone Call Policy:

You are welcome to call between appointment times with the understanding if the call lasts more than 10 minutes the standard billing fees will be in effect.

Cancellation Policy:

Notify the office as soon as possible if you are not able to keep your appointment. You will be charged your regular fee if cancellations are made less than 24 hours in advance. Insurance companies are not responsible for payment when appointments are not kept by the client. Therefore you will be the person responsible for paying the fee for the missed appointment.

I have read, understand and agree to the policies outlined above.

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