Ann Arbor Psychiatry Intake Form

Demographics
Name

First NameLast Name
Birth Date

MonthDayYear
Date
Current Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com

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
REQUIRED: How many psych hospitalizations have you had, at what ages, and what was the safety issue that resulted in hospitalization?*
You can adjust the size of the writing area by clicking on the bottom right of the window
REQUIRED: How many suicide attempts have you had? What ages? Were any of them primarily "cries for help"?*
You can adjust the size of the writing area by clicking on the bottom right of the window
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?*
You can adjust the size of the writing area by clicking on the bottom right of the window
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.*
You can adjust the size of the writing area by clicking on the bottom right of the window

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!
OPTIONAL: What issues have you had with other clinicians in the past? Why did you choose this clinic- or this clinician- in particular?
You can adjust the size of the writing area by clicking on the bottom right of the window
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: Relationship to you (primary care doctor? therapist?) 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)

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

YesNo
How long is this release valid?

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.
Signing below indicates agreement to above policies*

I agree
Sign here*

Clear

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

Never had any issues with obsessions or compulsionsThere 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 daysIn the past I’ve had problems with obsessions or compulsions
Tell us more about obsessions or compulsions in your life past and present.
You can adjust the size of the writing area by clicking on the bottom right of the window

Lashing Out / Anger
REQUIRED: SCREENING: The following apply to anger / lashing out:*

No issues with lashing outLash out verbally by saying snippy thingsLash out verbally by cursingLash out verbally by yellingLash out verbally by making threatsLash out verbally by saying cruel thingsLash out physically by throwing things or breaking thingsLash out physically by hitting peopleother
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).
You can adjust the size of the writing area by clicking on the bottom right of the window

Medical Issues
REQUIRED: Tell us about any past or present medical issues you have. *
You can adjust the size of the writing area by clicking on the bottom right of the window
REQUIRED: Please list ALL of your current medications (both psych and otherwise). If possible, list dosing and timing of medications as prescribed. *
You can adjust the size of the writing area by clicking on the bottom right of the window
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
You can adjust the size of the writing area by clicking on the bottom right of the window

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.*
You can adjust the size of the writing area by clicking on the bottom right of the window
OPTIONAL: Which of the above substances have you had phases of using more than 3 times a week? When?
You can adjust the size of the writing area by clicking on the bottom right of the window

	No Impact	Mild Impact	Moderate Impact	Severe Impact
Home
School
Work
Social Situations
Community (stores, restaurants, etc)
Extracurricular activities
Driving

	No Impact	Mild Impact	Moderate Impact	Severe Impact
Home
School
Work
Social Situations
Community (stores, restaurants, etc)
Extracurricular activities
Driving

	No Impact	Mild Impact	Moderate Impact	Severe Impact
Home
School
Work
Social Situations
Community (stores, restaurants, etc)
Extracurricular activities
Driving

	No Impact	Mild Impact	Moderate Impact	Severe Impact
Home
School
Work
Social Situations
Community (stores, restaurants, etc)
Extracurricular activities
Driving

	No Impact	Mild Impact	Moderate Impact	Severe Impact
Home
School
Work
Social Situations
Community (stores, restaurants, etc)
Extracurricular activities
Driving

Demographics

Ann Arbor Psychiatry Automated Clinical Interview

Insurance / Extended Demographics

History of Psychiatric Treatment

Goals

HIPAA

Treatment Contract

ADHD

Anxiety

Depression

Mania

OCD

Lashing Out / Anger

Medical Issues

Social History

Psychological

Substances Abuse

Clinic Policies