Ann Arbor Psychiatry Intake Form

  • Demographics

  • Birth Date
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  • Current Date
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  • 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.

  • 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 and Collaboration of Care

    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.
  • 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)
  • Is this release reciprocal (meaning that the therapist or PCP can speak with us as well)?

  • 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.

  • ADHD

  • REQUIRED: Are you scheduling because you are concerned about inattention/hyperactivity OR are you currently being treated for ADHD?*
  • One symptom of ADHD can involve rushing through tasks that require concentration. Sadly and ironically this set of questions about ADHD is actually quite taxing on ADHD. It can NOT be rushed through and does require at least 30-60 minutes of time spent describing 1) examples of each symptom reported to occur often and 2) describing the impact of each symptom on functioning. Please take breaks as needed.
  • 1. How often do you fail to give close attention to detail, or make careless mistakes? (ie overlook details, work is inaccurate)
  • 2. How often do you have difficulty sustaining your attention? (ie difficulty remaining focused in lectures, conversations, or lengthy reading/writing)
  • 3. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly? (ie mind elsewhere, mishearing things, needing people to repeat themselves, not following directions)
  • 4. How often do you have trouble finishing tasks? (ie starts tasks but get sidetracked, not finishing chores, schoolwork, workplace assignments)
  • 5. How often do you have difficulty organizing tasks or activities or time? (ie difficulty with sequential tasks, keeping items in order, messy, disorganized, poor time management, not meeting deadlines)
  • 6. How often do you avoid, dislike, or find yourself reluctant to engage in tasks requiring sustained focus? (ie schoolwork, preparing reports, completing forms, reviewing lengthy papers)
  • 7. How often do you misplace or have difficulty finding things? (ie school material, pens, books, tools, wallets, keys, paperwork, glasses, phones)
  • 8. How often are you distracted by extraneous stimuli? (ie irrelevant thoughts, background noise, visually jarring environment)
  • 9. How often are you forgetful in daily activities? (chores, errands, returning calls, paying bills, keeping appointments)
  • 10. How often do you fidget or squirm with your hands or feet?
  • 11. How often do you leave your seat in meetings or other situations in which you are expected to remain seated?
  • 12. How often do you run or climb in in appropriate situations, or feel inordinately restless?
  • 13. How often do you struggle to engage in leisure activities quietly?
  • 14. How often do you feel “on the go” as if “driven by a motor”? (ie uncomfortable being still for an extended time, struggle with sitting in restaurants or meetings, experienced by others as restless or difficult to keep up with)
  • 15. How often do you find yourself talking too much?
  • 16. When you’re in a conversation, how often do you find yourself blurting things out? (ie finishing other people’s sentences, answering questions prematurely, not waiting your turn in conversation, interrupting)
  • 17. How often do you have difficulty waiting your turn (ie finding waiting in lines inordinately difficult)?
  • 18. How often do you interrupt others when they are busy? (ie butting into conversations, taking over what someone else is doing)
  • IMPORTANT: In what areas of life is your performance significantly impacted by the above symptoms?*

  • Anxiety

  • REQUIRED: ANXIETY SCREENING: Which of the following regarding stress / tension / worry / anxiety has applied to you in life at some point? (we’ll just use the word stress as short hand for all of these)*
  • REQUIRED: SYMPTOMS: Which of the following symptoms, related at least in part to stress, have occurred at some point or another?*

  • REQUIRED: How frequently have you been experiencing some of the above anxiety symptoms in the last six months?*
  • REQUIRED: ANXIETY TRIGGERS: What tends to trigger excessive stress?*

  • OPTIONAL: ANXIETY IMPACT: How problematic are the symptoms of worry / anxiety / stress/ tension these days?

  • Depression

  • Do you have a history of low mood lasting days at a time? (Doesn't have to be current)*
  • REQUIRED MOOD SYMPTOMS/SCREENING: During your lowest moods which lasted at least a couple of days, which of the following symptoms occurred?*
  • OPTIONAL: LOW MOOD COURSE: What is the longest time duration that low mood periods have gone on for (where you felt persistently down)?
  • OPTIONAL: CONSEQUENCES of mood symptoms:

  • Mania

  • REQUIRED: MANIA SCREENING: Have you ever had a phase, lasting more than 4 days, that was DIFFERENT FROM YOUR USUAL SELF, where you had a lot of extra energy or irritability or confidence?*
  • REQUIRED: During this phase, which of the following applied:*

  • OCD

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

  • Lashing Out / Anger

  • REQUIRED: SCREENING: The following apply to anger / lashing out:*

  • 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

  • OPTIONAL: Select a few words that describe your overall temperament most of the time.
  • OPTIONAL: What effects did childhood difficulties have on your personality later in life?

  • Substances Abuse

  • Clinic Policies

  • Privacy Policy
    At Ann Arbor Psychiatry, we respect and protect the privacy of our clients. All personal and health information collected is used solely to provide you with the best care and support. We do not share, sell, or disclose your information to third parties unless required by law or with your explicit consent for coordination of care. Your information is securely stored and handled with strict confidentiality.

    Terms and Conditions
    By accessing and using our services at Ann Arbor Psychiatry, you agree to our terms and conditions. Our services are designed to provide mental health support and are not substitutes for emergency medical treatment. Appointments, cancellations, and rescheduling are subject to our clinic's policies, and fees may apply for late cancellations. We reserve the right to modify these terms as needed; any updates will be posted on our website. Please consult our team with any questions regarding these terms.

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