Ann Arbor Psychiatry Intake Form

History of Psychiatric Treatment
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REQUIRED: How many psych hospitalizations have you had, at what ages, and what was the safety issue that resulted in hospitalization? *
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REQUIRED: How many suicide attempts have you had? What ages? Were any of them primarily "cries for help"? *
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REQUIRED: How often do you self injure (ie cutting, burning, hitting self)? What kind of self injury? At your peak how often were you self injuring? *
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REQUIRED: This is a very important question, so take your time with it. Please list all of the psych medications you have ever tried. Next to each medication indicate if it was helpful or not, and why it was stopped. *
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Goals
It's a long intake form, so feel free to skip anything listed as optional unless you have the time and stamina!
OPTIONAL: What issues have you had with other clinicians in the past? Why did you choose this clinic- or this clinician- in particular?
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OPTIONAL: What are your hopes for this first encounter?
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OPTIONAL: What are the main issues you hope to address? How long has this been going on?
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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.
Please list clinics, therapists, and PCPs who we can collaborate with and send our intake evaluation to. If possible, give us any kind of contact information you can.
Clinician Name:
Clinic Name:
Phone/Email/Fax?:

Clinician Name:
Clinic Name:
Phone/Email/Fax?: You can adjust the size of the writing area by clicking on the bottom right of the window
Do we have permission to send them our intake evaluation or other records that would be helpful for your care? (You can withdraw permission at any time)

Yes No
Is this release reciprocal (meaning that the therapist or PCP can speak with us as well)?

Yes No
How long is this release valid?

OCD
REQUIRED: SCREENING: Which of the following apply to you regarding obsessions or compulsions? *

Never had any issues with obsessions or compulsions There are current problems with repetitive, intrusive, bothersome thoughts? (obsessions) There are current problems with compulsive behaviors? (compulsions) Obsessions or compulsions take up more than 20 minutes of my time some days In the past I’ve had problems with obsessions or compulsions
Tell us more about obsessions or compulsions in your life past and present.
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Lashing Out / Anger
REQUIRED: SCREENING: The following apply to anger / lashing out: *

No issues with lashing out Lash out verbally by saying snippy things Lash out verbally by cursing Lash out verbally by yelling Lash out verbally by making threats Lash out verbally by saying cruel things Lash out physically by throwing things or breaking things Lash out physically by hitting people other
OPTIONAL: If you feel like it, tell us more about lashing out. How often does the most severe kind of lashing out happen? How do you feel afterward? What kind of things are you sensitized to that trigger this (ie disrespect, loss of control, confrontation).
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Medical Issues
REQUIRED: Tell us about any past or present medical issues you have. *
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REQUIRED: Please list ALL of your current medications (both psych and otherwise). If possible, list dosing and timing of medications as prescribed. *
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REQUIRED: ALLERGIES? Please list any medications you are allergic to. *
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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?
OPTIONAL: Tell us about yourself
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Substances Abuse
REQUIRED: What substances (MJ, prescription pills, alcohol, cocaine, meth, crack, hallucinogens, inhalants, cigarettes, analogues, opioids) have you used to get high or escape in the last few months? What about years? Please also list any illicit substances tried and when. *
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OPTIONAL: Which of the above substances have you had phases of using more than 3 times a week? When?
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Demographics