• 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!
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  • What are the problem(s) for which you seek help?


  • Suicide Risk Assessment:

  • If YES, please answer the following questions. If NO, please skip to the next section.
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  • Past Medical History:

  • For women only:
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  • Personal and Family Medical History:

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  • Past Psychiatric History:

  • 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).
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  • Your Exercise Level:

  • Family Psychiatric History:

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  • Substance Use:

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  • Tobacco History:

  • Pipe, cigars, or chewing tobacco:
  • Family Background and Childhood History:

  • Trauma History:

  • Educational History:

  • Occupational History:

  • Relationship History and Current Family:

  • Legal History:

  • Spiritual Life:

  • Clear
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  • Clear
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  • For office use only:

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  • Should be Empty: