Intake Form

Intake Form
James Christopher Bentley, LCSW
www.jamescbentley.com
(901) 316-6542
jamesbentley986@gmail.com
Personal Information
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security Number
Phone Number

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Sex
Are you currently:
Are you currently:
Occupation / Employer
Name of Insurance Company
If none, please type None in all related fields.
ID Number
Group Number
Insured's Name

First NameLast Name
Insured's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Insured's Social Security Number
Insured's Employer
If possible, please upload a photo of the front and back of your insurance card.

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Secondary Insurance Company
Only need to fill out this section is applicable.
Secondary ID Number
Secondary Group Number
Secondary Insured's Name

First NameLast Name
Secondary Insured's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Secondary Insured's Social Security Number
Secondary Insured's Employer
If possible, please upload a photo of the front and back of your secondary insurance card.

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Emergency Contact

First NameLast Name
Relationship to you
Phone Number

Area CodePhone Number
Please list the problem(s) which you are seeking help?
Current Symptoms

Other
Have you ever had feelings or thoughts that you didn't want to live?
Do you currently feel that you don't want to live?
If yes, how often do you have these thoughts?
Do you feel hopeless and/or worthless?
Have you ever tried to kill or harm yourself?
Medical History
Primary Care Physician

First NameLast Name
Primary Care Physician's Phone Number

Area CodePhone Number
Previous Therapist / Counselor

First NameLast Name
Do you have any allergies?
If yes, please list them.
Current Weight
Current Height
List all current prescription medications and how often you take them.
Current medical problems
Past medical problems, nonpsychiatric hospitalization, or surgeries
Psychiatric History
Have you ever had outpatient treatment?
If yes, please describe when, by whom, and nature of treatment.
Have you ever had a psychiatric hospitalization?
If yes, please describe when, by whom, and nature of treatment.
Check if you have ever abused the following

Other
Past Psychiatric Medications

If you have ever taken any of the following medications, please indicate the dates and daily dosage.

Rows		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)
I have not taken any of the above medications.

Family Psychiatric History
Has anyone in your family been diagnosed with or treated for:

Other
Has any family member been treated with a psychiatric medication?
If yes, who in your family was treated, what medications did they take, and how effective was the treatment?
Tobacco History
Have you ever smoked cigarettes?
If yes, how many packs per day?
If yes, how many years?
Family Background and Childhood History
Were you adopted?
Where did you grow up?
Do you have any siblings?
If yes, list your siblings and their ages.
Did your parents divorce?
Do you have a history of being abused emotionally, sexually, physically or by neglect?
If yes, please describe when, where, and by whom.
Personal History
Highest grade/degree completed?
Do you have any children?
If yes, please list ages and gender.
Do you exercise regularly?
How many caffeinated beverages do you drink a day?
Have you ever been arrested?
Do you have any additional information to add?
Telemental Health Consent
Overview
What is Telemental Health?
Benefits and Risks of Telemental Health

Telemental Health services are using the internet and video conferencing software. Because during appointments, internet technology is used, there may be a disconnection and other difficulties that are the direct result of the low internet speed. Telemental Health services enable patients and specialists to communicate if patients have barriers such as transportation or illness, especially during the pandemic.
Communication Plan

Desired communication for Telemental Health services is videoconferencing technology. Hence, at first, specialists/therapists try to provide services on videoconferencing software during the appointment date and time. If this is not successful because of the low quality of the video, low internet speed, or any other technical difficulties, specialists/therapists will call patients at the phone number. It is advised to patients to connect 5-10 minutes prior to the appointment time and check whether the internet speed, webcam, and microphone work properly as expected.
Security and Privacy
Your signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Personal Information

Medical History

Psychiatric History

Past Psychiatric Medications

Family Psychiatric History

Tobacco History

Family Background and Childhood History

Personal History

Telemental Health Consent