Mental Health Intake Form

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
Date
Date of Birth *

Month Day 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
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

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
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:

	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

	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

	Dates	Dosage	Response/Side Effects	Other
Tegretol (carbamazepine)
Lithium
Depakote (valproate)
Lamictal (lamotrigine)
Tegretol (carbamazepine)
Topamax (topiramate)
Other

Antipsychotics/Mood Stabilizers

	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

	Dates	Dosage	Response/Side Effects	Other
Ambien (zolpidem)
Sonata (zaleplon)
Rozerem (ramelteon)
Restoril (temazepam)
Desyrel (trazodone)
Other

ADHD Medications

	Dates	Dosage	Response/Side Effects	Other
Adderall (amphetamine)
Concerta (methylphenidate)
Ritalin (methylphenidate)
Strattera (atomoxetine)
Other

Anti-anxiety Medications

	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:

	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:

	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? *

	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 *

Clear
Today's Date *

Month Day Year
Date
Guardian Signature (if under 18)

Clear
Today's Date

Month Day 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
Date
Reviewed by:

First Name Last Name
Date

Month Day Year
Date
Should be Empty:

Mental Health Intake Form

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

Suicide Risk Assessment:

Past Medical History:

Personal and Family Medical History:

Past Psychiatric History:

Past Psychiatric Medications:

Your Exercise Level:

Family Psychiatric History:

Substance Use:

Tobacco History:

Family Background and Childhood History:

Trauma History:

Educational History:

Occupational History:

Relationship History and Current Family:

Legal History:

Spiritual Life:

For office use only: