Intake Form
Barbara A. Morris Jensen, Psy.D., Licensed Clinical Psychologist #PSY20733
Date
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Month
 -
Day
Year
Date
Name
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First Name
Last Name
Date of Birth
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Month
 -
Day
Year
Date
Social Security Number
Gender
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Phone Number
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Email
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example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
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First Name
Last Name
Phone Number
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Insurance Information
Name of Insurance Company
Name of Insured
Date of Birth of Insured
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Month
 -
Day
Year
Date
Employer of Insured
Policy Number
Group Policy Number
Occupational Information
Are you currently:
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Working
Student
Unemployed
Disabled
Retired
If working, on a scale of 1 to 10, (ten being strongest), how would you rate the quality of your work life?
Weak
1
2
3
4
5
6
7
8
9
Strong
10
1 is Weak, 10 is Strong
Personal History
Are you currently:
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Married
Partnered
Divorced
Single
Widowed
If yes, on a scale of 1 to 10, (ten being strongest), how would you rate the quality of your relationship?
Weak
1
2
3
4
5
6
7
8
9
Strong
10
1 is Weak, 10 is Strong
Do you have any children?
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Yes
No
If yes, on a scale of 1 to 10, (ten being strongest), how would you rate the quality of your relationship with your child/children?
Weak
1
2
3
4
5
6
7
8
9
Strong
10
1 is Weak, 10 is Strong
List your children, if any, and their ages:
In the last year, have you had any major life changes (e.g. new job, new home, new baby, serious illness, relationship change, family challenges, financial challenges, etc.)?
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Yes
No
If yes, please list.
List your strengths:
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List areas you need to develop:
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How do you currently cope with stress and obstacles?
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What are you goals for therapy? What would you like to accomplish?
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Please list the problem(s) which you are seeking help?
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Current Symptoms
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Sleep pattern disturbance
Depressed mood
Change in appetite
Fatigue
Physical complaints
Crying spells
Anxiety attacks
Unable to enjoy activities
Racing thoughts
Loss of interest
Excessive worry
Excessive guilt
Anger/irritability
Decreased need for sleep
Concentration/forgetfulness
Hallucinations
Increased irritability
Suspiciousness
Confused or Irrational Thinking
Increase risky behavior
Repetitive thoughts or behaviors
Excessive energy
Self-mutilation
Other
Life evaluation:
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Â
Yes
No
Do you feel hopeless and/or worthless?
Have you ever tried to kill or harm yourself before?
Is there anything that would stop you from killing yourself?
Do you engage in any form of self-harm?
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Yes
No
If yes, please list.
Have you had any suicidal thoughts recently?
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Yes
No
If yes, on a scale of 1 to 10, (ten being strongest) how strong is your desire to end your life currently?
Weak
1
2
3
4
5
6
7
8
9
Strong
10
1 is Weak, 10 is Strong
If yes, how often do you have these thoughts?
Frequently
Sometimes
Rarely
Have you had suicidal thoughts in your past?
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Yes
No
Have you ever had any homicidal thoughts?
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Yes
No
Please describe.
Medical History
Primary Care Physician
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First Name
Last Name
Primary Care Physician Phone Number
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Do you have any current medical conditions?
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Yes
No
If yes, please list.
Are you currently taking any prescription medications for medical conditions?
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Yes
No
If yes, please list.
Do you have any allergies? (If yes, please list them)
List all current prescription medications and how often you take them
Past medical problems, nonpsychiatric hospitalization, or surgeries
How many caffeinated beverages (coffee, tea, energy drinks, etc.)do you drink per day?
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Exercise Level
Do you exercise regularly?
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Yes
No
How many times per week do you exercise?
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0
1-2
3-4
5-7
Tobacco History
Have you ever smoked cigarettes?
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Yes
No
How many packs per day?
How many years?
Alcohol and Drug History
How many alcoholic drinks do you consume per week?
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Do you use recreational drugs?
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Yes
No
Check if you have ever tried the following:
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Methamphetamine
Cocaine
Stimulants (pills)
Heroin
LSD or Hallucinogens
Marijuana
Pain killers (not as prescribed)
Methadone
Tranquilizer/sleeping pills
Alcohol
Ecstasy
Other
Family Background and Childhood History:
Were you adopted?
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Yes
No
Did your parents divorce?
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Yes
No
List your siblings, if any, and their ages:
Psychiatric History:
Have you had any mental health services in the past?
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Yes
No
If yes, please describe when, by whom, and nature of treatment
Psychiatric Hospitalization
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Yes
No
If yes, Please describe when, by whom, and nature of treatment
Have you ever been arrested?
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Yes
No
Psychiatric Medications
Are you currently taking any psychiatric prescription medications?
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Yes
No
If you have ever taken any of the following medications, please indicate the dates and daily dosage.
Â
Have you ever taken it?
Dates
Dosage
Side Effects?
Prozac (fluoxetine)
Zoloft (sertraline)
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)
Tegretol (carbamazepine)
Lithium
Depakote (valproate)
Lamictal (lamotrigine)
Tegretol (carbamazepine)
Topamax (topiramate)
Seroquel (quetiapine)
Zyprexa (olanzepine)
Geodon (ziprasidone)
Abilify (aripiprazole)
Clozaril (clozapine)
Haldol (haloperidol)
Prolixin (fluphenazine)
Risperdal (risperidone)
Ambien (zolpidem)
Sonata (zaleplon)
Rozerem (ramelteon)
Restoril (temazepam)
Desyrel (trazodone)
Adderall (amphetamine)
Concerta (methylphenidate)
Ritalin (methylphenidate)
Strattera (atomoxetine)
Xanax (alprazolam)
Ativan (lorazepam)
Klonopin (clonazepam)
Valium (diazepam)
Tranxene (clorazepate)
Buspar (buspirone)
Other medications?
Family Psychiatric History
Has anyone in your family been diagnosed with or treated for:
Bipolar disorder
Depression
Anxiety
Anger
Suicide
Schizophrenia
Post-traumatic stress
Alcoholabuse
Other
Do you have a history of being abused emotionally, sexually, physically or by neglect?
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Yes
No
If yes, please describe when, where and by whom.
Additional information that would be helpful for me to know:
Signature
*
Clear
Signature (Spouse, Significant Other, Other)
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Guardian Signature (if under age 18)
Clear
Please verify that you are human
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