• Demographics

  •  - -
    Pick a Date
  •  - -
    Pick a Date
  • Ann Arbor Psychiatry Automated Clinical Interview

  • Welcome to Ann Arbor Psychiatry! 

    This is a virtual clinical interview. Based on how you respond to questions, subsequent questions will self-adjust. PLEASE USE A COMPUTER (not a phone)!

    • We STRONGLY recommend using A COMPUTER instead of a phone as it may be easier to type out lengthy answers by keyboard.
    • It is a bit of a marathon. Feel free to pace yourself and skip any optional questions that don't speak to you. You can always go back to previous pages.
    • Answers here will be reviewed by your clinician to make the best use of your time in the office.
  • Insurance / Extended Demographics

  • Please be sure of your answer to the following question about if we have your insurance information. We have to delete intake appointments without this information, as we do not always have a receptionist on hand to take the information in the office.

  • History of Psychiatric Treatment

  • Goals

  • It's a long intake form and the symptom focused questions are most important, so feel free to skip anything listed as optional unless you have the time and stamina!

  • HIPAA

    The best care is delivered when all of your clinicians are in communication with one another. We send our intake evaluation to PCPs and therapists whenever possible so everyone is on the same page.
  • Treatment Contract

    Please read carefully and sign. This relates to if you are prescribed controlled substances with potential for addiction, abuse, or diversion.
  • As a participant in mental health/pain treatment, I freely and voluntarily agree to accept this treatment contract as follows:

    1. I agree to keep and be on time to all my scheduled appointments.

    2. I agree to adhere to the payment policy outlined by this office.

    3. I agree to conduct myself in a courteous manner in the provider's office.

    4. I agree not to sell, share, or give any of my medication to another person. I understand that such mishandling of my medication is a serious violation of this agreement and would result in my treatment being terminated without any recourse for appeal.

    5. I agree not to deal, steal, or conduct any illegal or disrupted activities in the provider's office.

    6. I understand that if dealing, stealing, or any illegal or disruptive activities are observed or suspected by employees of the pharmacy where my medication is filled, that the behavior will be reported to my provider’s office and could result in my treatment being terminated without recourse for appeal.

    7. I agree that the medication/prescription can only be given to me at my regular office visit. A missed visit may result in my being unable to get my medication/prescription until my next scheduled visit.

    8. I agree that the medication I received is my responsibility and I agree to keep it in a safe, secure place. I agree that lost medication may not be replaced regardless of why it was lost.

    9. I agree not to obtain medications from any other providers, pharmacies, or other sources without telling my treating physician.

    10. I understand that mixing medications, especially benzodiazepines (for example, Valium, Klonopin, or Xanax) can be dangerous. I also recognize that several deaths have occurred among persons mixing medications and benzodiazepine (especially if taken outside the care of a physician/provider, using routes of administration other than oral or in higher than recommended therapeutic doses).

    11. I agree to take my medication as my provider has instructed and not to alter the way I take my medication without first consulting my doctor.

    12. I understand the medication alone is not sufficient treatment for my condition, and I agree to participate in additional recommended treatment as discussed and agreed upon with my provider and specified in my treatment plan.

    13. I agree to abstain from cocaine, opioids, and other addictive substances (excepting nicotine).

    14. I agree to provide random urine or saliva samples and have my provider test my blood alcohol level and random pill counts per the provider's discretion.

    15. I understand that violations of the above may be grounds for termination of treatment.

  • Clear
  • ADHD


  • Anxiety



  • Depression

  • Mania

  • OCD

  • Lashing Out / Anger

  • Medical Issues

  • Social History

  • Optional: Tell us about yourself. 

    Were you raised by one or two parents? Biological or Adopted?

    Any difficult or unusual aspects of childhood? Divorce? Moves? Bullying?

    Physical or sexual abuse of any kind?

    How far did you go in school?

    Who do you live with? How do you currently pay the bills? 

     

  • Psychological

  • Substances Abuse

  • Clinic Policies

  • Should be Empty: