New Client Intake Form

New Client Intake Form

Orchard Human Services, Inc.
Name:
Date:

MonthDayYear
Date
Nickname or Preferred Name:
Parent/Legal Guardian (if under 18):
Legal Gender at Birth
Gender Identification and Pronouns
Address Street, Apartment, Unit
Address City, State, Zip
Home Phone:
May we leave a message?
Cell/Work/Other Phone:
May we leave a message?
Email:
May we leave a message?
Please Note; Email correspondence is not considered to e a confidential medium of communication.
Date of Birth:

MonthDayYear
Date
Age
Marital Status
Referred By (if any):
OR - If not referred, then:
How did you hear about us?
Reason for requesting services with this facility/practitioner?
Please describe any past counseling or mental health services that you have received in the past:
If you had previous services, what did you like? What was effective or helpful?
Medical History
Who is your primary care provider?
Doctor's Name:
Phone Number:
Address:
Date of your last medical examination:

MonthDayYear
Date
Do we have permission to contact your doctor to promote continuity of care?

YesNo
Did your mother smoke tobacco or use any alcohol, drugs or medications during her pregnancy with you? If so, please list which ones:
Did your mother have any problems during the pregnancy or at delivery? If so, please describe them:
Have you experienced any of the following medical problems?

A Serious accidentHospitalizationSurgeryAsthmaHead InjuryHigh ferverConvulsions/seizuresEye/ear problemsMeningitisHearing problemsAllergiesLoss of consciousnessOther
Please list any current medical problems or physical handicaps:
Please last any previous surgeries, serious accidents or injuries, medical diagnoses, or medical problems:
Please list any medications you take on a regular basis:
Please Indicate if you use any of the following:

AlcoholRecreational DrugsTobacco ProductsOther Mind-Altering Substances
Mental Health History
Have you previously received any type of mental health services psychotherapy, psychiatric services, etc?

YesNo
Please list:
For continuity of care and following Georgia State law we are required review any previous medical records related to your mental health care. Do you agree to send all relevant medical records for review to our secure Fax line at 1-877-660-8884*
Are you currently taking any prescription medication?
Please list medications and dates proscribed:
Have you ever been prescribed psychiatric medication

YesNo
Please list medications and dates proscribed
General and Mental Health Information
1. How would you rate your current physical health?
Please list any specific health problems you are currently experiencing:
2. How would you rate your current sleeping habits?
Do you have any specific sleep problems you are currently experiencing, if yes please list:
3. How many times per week do you generally exercise?
What types of exercise do you participate in?
4. Please list any difficulties you experience with your appetite or eating problems:
5. Are you currently experiencing overwhelming sadness, grief or depression?
For how long?
6. Are you currently experiencing anxiety, panics attacks or have any phobias?
When did you begin experiencing this?
7. Are you currently experiencing any chronic pain?
Please describe:
8. Do you drink alcohol more than once a week?
How many days a week do you drink?
How many drinks a week?
9. How often do you engage in recreational drug use?
10. Are you currently in a romantic relationship?
If yes, for how long?
On a scale of 1-10 with 1 being poor and 10 being exceptional, how would you rate your relationship and why?
11. What significant life changes or stressful events have you experienced recently?
Mental Health History
Alcohol/Substance Abuse
Anxiety
Depression
Domestic violence
Intimate Partner Violence
Self-Harm
Eating Disorders
Obsessive Compulsive Behavior
Obesity
Schizophrenia
Suicide Attempts
Mental Health Diagnosis
Sexual Abuse
Physical Abuse
Other Concerning Situation
Who is your primary care provider?
Type a question
All About You
Are you currently employed?
What is your current employment situation?
Do you enjoy your work? Is there anything stressful about your current work?
2. Do you consider yourself to be spiritual or religious?
Please describe your faith or belief:
3. What do you consider to be some of your strengths?
4. What do you consider to be some of your weaknesses?
5. What would you like to accomplish out of your time in therapy?
Is there anything else about your history you would like us to know?
Do you ever think about wanting to hurt yourself or seriously hurt someone else?
Please describe the situation:
Have you ever purposely hurt yourself or another person?
Please describe the situation:
Do you have a trauma history [have you ever experienced trauma, abuse, neglect, or a major disaster/loss/life event]?
Please explain:
Have you ever experienced any serious emotional losses (such as a death of or physical separation from an important person in your life ... such as a spouse, life partner, child, parent, caretaker, etc.)?
Please explain:
What are some of the things that are currently stressful to you – and if it applies to you, that are stressful to your family or close circle of friends/business associates/life partner/etc.:
Additional Information

Please complete IF THIS APPLIES TO YOU. Then move on to sign and submit.
ADDITIONAL INFORMATION – Complete if one of the following applies to you, then move on to sign and submit:
You are an adult or young adult who is still in school.You are an adult who is dealing with issues that may be impacted by learning or memory problems, childhood events or relationships, developmental issues, bullying that date back to childhood or adolescence, and school experiences.
Additional Information - Behavioral Excesses
Behavioral Excesses: As a child or adolescent, what did you do too often, too much, or at the wrong times that got you in trouble? Please list all the behaviors you can think of:
Behavioral Deficits: As a child or adolescent, what did you fail to do as often as you should have, as much as you should have, or when you would like? Please list all the behaviors you can think of:
Behavioral Assets: What did you do as a child that you liked? What did you do that other people like?
Others Concerns: Do you have any other concerns about your experiences during childhood or adolescence that you would like to share, discuss, or that still boher you?
Additional Information - Treatment Goals
From your preceding list of your behavior and personal concerns, what problem behaviors do you want to see change FIRST: and how much must they change for you to be satisfied?
When you were a child, who were the other household members? Please list their name, age, and relationship to child:
Who were significant others who did NOT live with you when you were a child? Please list their name, age, and relationship to the child:
Additional Information - Education/Profession
What schools did you attend? What degrees or credentials have you earned? Please list:
What things did your teachers or instructors say about you? How would your teachers/instructors describe you?
Have you ever repeated a grade? If so which one(s)?
Have you ever received special education services?
Type a question

FightingLack of friendsDrug/AlcoholDetentionSuspentionLearning DisabilitiesPoor AttendancePoor GradesGang InfluencesIncomplete HomeworkBehavior Problems
By continuing I understand that I must send a copy of my ID to forms@orchardhumanservices.org
By continuing you understand that if you would like us to process your insurance you must include a photo of your card by sending it to forms@orchardhumanservices.org
FINAL STEP - Sign and Submit

By signing and dating below, I authorize Orchard Human Services, Inc. and its staff and representatives to provide care to myself or my minor child.
Signature*

Clear
I am signing as*
Printed Name of Signer*

First NameLast Name
Date Signed*

MonthDayYear
Date
Should be Empty:

New Client Intake Form

Medical History

Mental Health History

General and Mental Health Information

Mental Health History

All About You

Additional Information

FINAL STEP - Sign and Submit