Mental Health Intake Form
Please complete and submit before your first appointment. It may seem long, but most of the questions require only a check, so it will go quickly. You may need to ask family members about your family history. Thank you!
Name
*
First Name
Last Name
Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Care Physician
*
First Name
Last Name
Do you give permission for ongoing regular updates to be provided to your primary care physician?
*
Yes
No
Current Therapist/Counselor
First Name
Last Name
Therapist/Counselor Phone Number
-
Area Code
Phone Number
What are the problem(s) for which you seek help?
1.
*
2.
3.
What are your treatment goals?
*
Current Symptoms Checklist
*
Depressed Mood
Unable to enjoy activities
Sleep pattern disturbance
Loss of interest
Concentration/forgetfulness
Change in appetite
Excessive guilt
Fatigue
Decreased libido
Racing thoughts
Impulsivity
Increased risky behavior
Increased libido
Decreased need for sleep
Excessive energy
Increased irritability
Crying spells
Excessive worrying
Anxiety attacks
Avoidance
Hallucinations
Suspiciousness
Other
Suicide Risk Assessment:
Have you ever had feelings or thoughts that you didn't want to live?
*
Yes
No
If YES, please answer the following questions. If NO, please skip to the next section.
Do you currently feel that you don't want to live?
Yes
No
How often do you have these thoughts?
When was the last time you had thoughts of dying?
Has anything happened recently to make you feel this way?
On a scale of 1 to 10 (10 being strongest), how strong is your desire to kill yourself currently?
1
2
3
4
5
6
7
8
9
10
Very Weak
Very Strong
1 is Very Weak, 10 is Very Strong
Would anything make it better?
Have you ever thought about how you would kill yourself?
Is the method you would use readily available?
Have you planned a time for this?
Is there anything that would stop you from killing yourself?
Do you hopeless and/or worthless?
Have you ever tried to kill or harm yourself before?
Do you have access to guns? If yes, please explain.
Past Medical History:
Allergies
Please list any allergies if applicable.
Height
*
Weight
*
List ALL current prescription medications and how often you take them.
Current over-the-counter medications or supplements:
Current medical problems:
Past medical problems, non-psychiatric hospitalization, or surgeries:
Have you ever had an EKG?
*
Yes
No
If yes, when?
Was the EKG:
Normal
Abnormal
Unknown
For women only:
Date of last menstrual period:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Are you currently pregnant or do you think you might be pregnant?
Yes
No
Are you planning to get pregnant in the near future?
Yes
No
Birth Control Method (if applicable)
How many times have you been pregnant?
How many live births?
Do you have any concerns about your physical health that you would like to discuss with us?
Yes
No
Please list the date and place of your last physical exam.
Personal and Family Medical History:
Rows
Yout
Family
Which Family Member?
Details (if applicable)
Thyroid Disease
Anemia
Liver Disease
Chronic Fatigue
Kidney Disease
Diabetes
Ashtma/respiratory problems
Stomach or intestinal problems
Cancer (please list type in right most column)
Fibromyalgia
Heart Disease
Epilepsy or seizures
Chronic pain
High Cholesterol
High blood pressure
Head trauma
Liver problems
Other (please type in right most column)
Is there any additional medical history? If yes, please explain:
When your mother was pregnant with you, were there complications during the pregnancy or birth?
Past Psychiatric History:
Outpatient treatment? If yes, please describe for what reason, by whom, and nature of treatment:
Psychiatric hospitalization?
Past Psychiatric Medications:
If you have every taken any of the following medications, please indicate the dates, dosage, and how helpful they were (if you can't remember all the details, just write in what you do remember).
Antidepressants
Rows
Dates
Dosage
Response/Side Effects
Other
Prozac (fluoxetine)
Zoloft (sertaline)
Luvox (fluvoxamine)
Paxil (paroxetine)
Celexa (citalopram)
Lexapro (escitalopram)
Effexor (venlafaxine)
Cymbalta (duloxetine)
Wellbutrin (bupropion)
Remeron (mirtazapine)
Serzone (nefazodone)
Anafranil (clomipramine)
Pamelor (nortrptyline)
Tofranil (imipramine)
Elavil (amitriptyline)
Other
Mood Stabilizers
Rows
Dates
Dosage
Response/Side Effects
Other
Tegretol (carbamazepine)
Lithium
Depakote (valproate)
Lamictal (lamotrigine)
Tegretol (carbamazepine)
Topamax (topiramate)
Other
Antipsychotics/Mood Stabilizers
Rows
Dates
Dosage
Response/Side Effects
Other
Seroquel (quetiapine)
Zyprexa (olanzepine)
Geodon (ziprasidone)
Abilify (aripiprazole)
Clozaril (clozapine)
Haldol (haloperidol)
Prolixin (fluphenazine)
Risperdal (risperidone)
Other
Sedatives/Hypnotics
Rows
Dates
Dosage
Response/Side Effects
Other
Ambien (zolpidem)
Sonata (zaleplon)
Rozerem (ramelteon)
Restoril (temazepam)
Desyrel (trazodone)
Other
ADHD Medications
Rows
Dates
Dosage
Response/Side Effects
Other
Adderall (amphetamine)
Concerta (methylphenidate)
Ritalin (methylphenidate)
Strattera (atomoxetine)
Other
Anti-anxiety Medications
Rows
Dates
Dosage
Response/Side Effects
Other
Xanax (alprazolam)
Ativan (lorazepam)
Klonopin (clonazepam)
Valium (diazepam)
Tranxene (clorazepate)
Buspar (buspirone)
Other
Your Exercise Level:
Do you exercise regularly?
*
Yes
No
How many days a week do you get exercise?
*
How much time each day do you exercise?
What kind of exercise do you do?
Family Psychiatric History:
Has anyone in your family been diagnosed with or treated for:
Rows
Yes
No
Bipolar disorder
Depression
Post-traumatic stress
Anxiety
Alcohol abuse
Anger
Other substance abuse
Suicide
Schizophrenia
Violence
If yes, who had each problem?
Has any family member been treated with a psychiatric medication?
*
Yes
No
If yes, who was treated, what medications did they take, and how effective was the treatment?
Substance Use:
Have you ever been treated for alcohol or drug use or abuse?
*
Yes
No
If yes, for which substances?
If yes, where were you treated and when?
How many days per week do you drink any alcohol?
*
What is the least number of drinks you will drink in a day?
What is the most number of drinks you will drink in a day?
In the past three months, what is the largest amount of alcoholic drinks you have consumed in one day?
*
Have you ever felt you ought to cut down on your drinking or drug use?
*
Yes
No
Have people annoyed you by criticizing your drinking or drug use?
*
Yes
No
Have you ever felt bad or guilty about your drinking or drug use?
*
Yes
No
Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?
*
Yes
No
Do you think you may have a problem with alcohol or drug use?
*
Yes
No
Have you used any street drugs in the past 3 months?
*
Yes
No
If yes, which ones?
Have you ever abused prescription medication?
*
Yes
No
If yes, which ones and for how long?
Check if you have ever tried the following:
Rows
Yes
No
If yes, how long and when did you last use?
Methamphetamine
Cocaine
Stimulants (pills)
Heroin
LSD or Hallucinogens
Marijuana
Pain killers (not as prescribed)
Methadone
Tranquilizer/sleeping pills
Alcohol
Ecstasy
Other
How many caffeinated beverages do you drink a day?
*
Rows
How many?
Coffee
Sodas
Tea
Tobacco History:
How you ever smoked cigarettes?
*
Yes
No
Currently?
*
Yes
No
In the past?
*
Yes
No
How many years did you smoke?
When did you quit?
Pipe, cigars, or chewing tobacco:
Currently?
Yes
No
In the past?
Yes
No
What kind?
How often per day on average?
How many years?
Family Background and Childhood History:
Were you adopted?
*
Yes
No
Where did you grow up?
*
List your siblings and their ages:
What was your father's occupation?
What was your mother's occupation?
Did your parents divorce?
Yes
No
If so, how old were you when they divorced?
If your parents divorced, who did you live with?
Describe your father and your relationship with him:
Describe your mother and your relationship with her:
How old were you when you left home?
Has anyone in your immediate family died?
Who and when?
Trauma History:
Do you have a history of being abused emotionally, sexually, physically or by neglect?
*
Yes
No
Please describe when, where and by whom:
Educational History:
Highest Grade Completed?
*
Where?
Did you attend college?
Where?
Major?
What is your highest educational level or degree attained?
Occupational History:
Are you currently:
*
Working
Student
Unemployed
Disabled
Retired
How long in present position?
What is/was your occupation?
Where do you work?
Have you ever served in the military?
*
Yes
No
If so, what branch and when?
Honorable discharge?
Yes
No
Other type of discharge?
Relationship History and Current Family:
Are you currently:
*
Married
Partnered
Divorced
Single
Widowed
How long?
If not married, are you currently in a relationship?
Yes
No
If yes, how long?
Are you sexually active?
Yes
No
How would you identify your sexual orientation?
straight/heterosexual
lesbian/gay/homosexual
bisexual
transsexual
unsure/questioning
asexual
other
prefer not to answer
What is your spouse or significant other's occupation?
Describe your relationship with your spouse or significant other:
Have you had any prior marriages?
Yes
No
If so, how many?
How long?
Do you have children?
Yes
No
If yes, list ages and gender:
Describe your relationship with your children:
List everyone who currently lives with you:
*
Legal History:
Have you ever been arrested?
*
Yes
No
Do you have any pending legal problems?
*
Spiritual Life:
Do you belong to a particular religion or spiritual group?
Yes
No
If yes, what is the level of your involvement?
Do you find your involvement helpful during this illness, or does the involvement make things more difficult or stressful for you?
More helpful
Stressful
Is there anything else that you would like us to know?
Signature
*
Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Guardian Signature (if under 18)
Today's Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
-
Area Code
Phone Number
For office use only:
Reviewed by:
First Name
Last Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reviewed by:
First Name
Last Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
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