New Patient Intake Forms

  • New Patient Intake Forms

    This information is required by your provider to conduct your initial assessment. Please complete it as thoroughly as possible. If any section does not apply to your reason for seeking an appointment, feel free to skip that section. Please answer honestly; this information is confidential. If you have any questions while completing these forms, please call our office at 612-436-0295.

  • Adult Symptom Screener

    Summary of Symptom Screening
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  • The following questions relate to your experiences of the last 6 months:

  • In the past 6 months, did you ever have a spell or an attack when all the sudden you felt frightened, anxious, or very uneasy?*
  • In the past 6 months, did you ever have a spell or an attack where for no reason your heart suddenly began to race, you felt faint, or you couldn't catch your breath?*
  • Did any of these spells or attacks ever happen in a situation when you were not in danger or not the center of attention?*
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  • Have you experienced any of the following traumatic events: natural disaster (e.g., flood, hurricane, tornado, earthquake), fire, explosion, or industrial accident; transportation accident (e.g., car accident, plane crash); physical assault (e.g., being attacked, beaten up); sexual assault (e.g., rape, attempted rape, made to perform any type of sexual act through force or threat of harm); captivity or exposure to a war-zone; life-threatening illness or injury; sudden, unexpected death of or injury to someone close to you; or serious injury, harm, or death to someone else that you witnessed or caused?*
  • Has this event caused any significant problems or symptoms that lasted for more than a month?*

  • Has there ever been a period of time when you were not your usual self and...

  • ...you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?*
  • ...you were so irritable that you shouted at people or started fights or arguments?*
  • ...you felt much more self-confident than usual?*
  • ...you got much less sleep than usual and found you didn't really miss it?*
  • ...you were much more talkative or spoke much faster than usual?*
  • ...thoughts raced through your head or you couldn't slow your mind down?*
  • ...you were so easily distracted by things around you that you had trouble concentrating or staying on track?*
  • ...you had much more energy than usual?*
  • ...you were much more active or did many more things than usual?*
  • ...you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?*
  • ...you were much more interested in sex than usual?*
  • ...you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?*
  • ...spending money got you or your family in trouble?*

  • The following questions relate to your eating habits:

  • When you eat, do you make yourself sick because you feel uncomfortably full?*
  • Do you ever worry that you have lost control over how much you eat?*
  • Have you recently lost more than 14 pounds in a 3 month period?*
  • Do you believe yourself to be fat when others say you are too thin?*
  • Would you say that food dominates your life?*
  • Have you ever been bothered by having to perform some ritual or act over and over that does not make sense?*

  • The following questions relate to your alcohol and substance use:

  • How often do you have a drink of alcohol?*
  • How many drinks containing alcohol do you have on a typical day when you are drinking?*
  • How often do you have six or more drinks on one occasion?*
  • In the past year have you used an illegal drug or used a prescription medication for non-medical reasons?*

  • Please answer the questions below, rating yourself on each of the criteria shown using the scale provided. As you answer each question, select the option that best describes how you have felt and conducted yourself over the past 6 months.

  • How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?*
  • How often do you have difficulty getting things in order when you have to do a task that requires organization?*
  • How often do you have problems remembering appointments or obligations?*
  • When you have a task that requires a lot of thought, how often do you avoid or delay getting started?*
  • How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?*
  • How often do you feel overly active and compelled to do things, like you were driven by a motor?*

  • The questions listed below relate to your thoughts and feelings. If the way you have been in recent weeks or months differs from the way you usually are, please answer based on when you were your usual self.

  • Do you find that most people will take advantage of you if you let them know too much about you?*
  • Do you generally feel nervous or anxious around people?*
  • Do you avoid situations where you have to meet new people?*
  • Do you avoid getting to know people because you're worried that they may not like you?*
  • Has avoidance of getting to know people due to fear of being disliked affected the number of friends that you have?*
  • Do you keep changing the way you present yourself to people because you don't know who you really are?*
  • Do you often feel like your beliefs change so much that you don't know what you really believe anymore?*
  • Do you often get angry or irritated because people don't recognize your special talents or achievements as much as they should?*
  • Have you had any unusual experiences such as hearing voices, seeing visions, or having ideas you later found out were not true?*
  • Have you had any other experiences, such as mind reading, ESP, thoughts beng controlled by others, seeing things on TV that refer to you specifically?*

  • CAGE-AID Questionnaire

    When thinking about drug use, include illegal drug use and the use of prescription drug use other than prescribed.
  • Have you ever felt that you ought to cut down on your drinking or drug use?*
  • Have people annoyed you by criticizing your drinking or drug use?*
  • Have you ever felt bad or guilty about your drinking or drug use?*
  • Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?*

  • Clinical History Form

    If you are filling this out on behalf of the patient, please answer from the patient's perspective.
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  • Substance Abuse History

    If you are filling this out on behalf of the patient, please answer from the patient's perspective.
  • Do you have a history of any recreational drug use?*
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  • Substance Abuse Treatment History

    If you are filling this out on behalf of the patient, please answer from the patient's perspective.
  • Did you receive any treatment for substance abuse?*

  • Consequences of Substance Abuse

  • Have you experienced any of these consequences as a result of alcohol consumption or abuse of substances? (Please check all that apply)*

  • Inpatient Psychiatric History

    If you are filling this out on behalf of the patient, please answer from the patient's perspective.
  • Do you have a history of inpatient psychiatric treatment?*

  • Outpatient Psychiatric History

    "Outpatient Psychiatric HIstory" means any mental healthcare you've received outside of a hospital, e.g., in a clinic, individual therapy, independent providers, etc.
  • Do you have a history of outpatient psychiatric treatment?*

  • Suicide/Self-Harm History

    If you are filling this out on behalf of the patient, please answer from the patient's perspective.
  • Have you ever tried to harm or kill yourself?*
  • Was your intent to die?*

  • Most Severe Episode

  • Most Recent Episode

  • Violence History Assessment

    If you are filling this out on behalf of the patient, please answer from the patient's perspective.
  • Have you had any history of violent behavior?*

  • Past Medical History

    If you are filling this out on behalf of the patient, please answer from the patient's perspective.
  • Are you taking any medications currently? (Excluding medications for psychiatric treatment)*
  • Have you a history of any of the following health problems? (Please check all that apply)*
  • Have you a history of surgery in any of the following areas? (Please check all that apply)*

  • Psychiatric Medication History

    If you are filling this out on behalf of the patient, please answer from the patient's perspective.
  • Have you ever taken any medication for psychiatric treatment?*
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  • Patient Allergies

  • Do you have any known allergies to medication?*
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  • Family History

    If you are filling this out on behalf of the patient, please answer from the patient's perspective.
  • Do you have any family members with a history of psychiatric illness?*

  • If YES, please elaborate below using the following options:

    Family Member: Mother, Father, Grandmother, Grandfather, Sister, Brother, Daughter, Son, Aunt, Uncle, Cousin

  • Developmental and Education History

  • During your pregnancy/birth, did your mother have any problems with any of the following:*
  • Did you have any complications after your birth? (e.g. premature birth, jaundice, breathing difficulties)*
  • Did you have any delays or difficulties in reaching the following developmental milestones?*
  • Which options below best describe your childhood home atmosphere?*
  • Which of the following challenges were experienced during your childhood?*
  • Which of the following best describe problems you may have had in school?*
  • Did you have additional schooling outside of the standard classroom setting? (Please check all that apply)*
  • Please select your highest level of education:*

  • General Social History

    If you are filling this out on behalf of the patient, please answer from the patient's perspective.
  • Which options below best describes your social situation?*
  • What is your current marital status?*
  • What is the status of your intimate relationship?*
  • What is the satisfaction level of your intimate relationship?*
  • What is your sexual orientation?*
  • What is your current living situation?*
  • Who do you currently live with? (Please check all that apply)*
  • Do you currently participate in spiritual activities?*
  • What is your current occupation status?*
  • What is your current yearly income?*

  • Menstruation and Pregnancy History

    If you are filling this out on behalf of the patient, please answer from the patient's perspective.
  • Which of these best describes your premenstrual symptoms?*
  • Do you have a method of contraception? (Check all that apply)*
  • Have you ever been pregnant?*
  • Have you ever given birth?*
  • Have you had any miscarriages?*
  • Have you had any abortions?*

  • Review of Systems

    Please look at the list of physical symptoms below and check off any that you have experienced in the last several days. If you have NOT experienced any symptoms in an area, be sure to check "None of the above" for that area. If you are filling this out on behalf of the patient, please answer from the patient's perspective.
  • Constitutional*
  • Eyes*
  • Ears, Nose, Mouth, and Throat*
  • Cardiovascular*
  • Respiratory*
  • Musculoskeletal*
  • Gastrointestinal*
  • Allergic/Immunologic*
  • Endocrine*
  • Hematologic/Lymphatic*
  • Genitourinary (General)*
  • Genitourinary (Women)*
  • Genitourinary (Men)*
  • Neurological*
  • Integumentary (Skin/Breast and Hair)*
  • Psychiatric*

  • GAD-7

    Please read each statement and select a number 0, 1, 2, or 3 which indicates how much the statement applied to you over the past two weeks. There are no right or wrong answers. Do not spend too much time on any one statement. This assessment is not intended to be a diagnosis. If you are concerned about your results in any way, please speak with a qualified health professional.
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  • Patient Health Questionnaire (PHQ-9)

    Over the last 2 weeks, how often have you been bothered by any of the following problems?
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  • Adverse Childhood Experience (ACE) Questionnaire

    While you were growing up, during your first 18 years of life:
  • Did a parent or other adults in the house often swear at you, insult you, put you down, or humiliate you OR act in a way that made you afraid you might be physically hurt?
  • Did a parent or other adults in the house often push, grab, slap, or throw something at you OR ever hit you so hard that you had marks or were injured?
  • Did an adult or person at least 5 years older than you ever touch or fondle you or have you touch their body in a sexual way OR try to or actually have oral, anal, or vaginal sex with you?
  • Did you often feel that no one in your family loved you or thought you were important or special OR your family didn't look out for each other, feel close to each other, or support each other?
  • Did you often feel that you didn't have enough to eat, had to wear dirty clothes, and had no one to protect you OR your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
  • Were your parents ever separated or divorced?
  • Was your mother or stepmother: often pushed, grabbed, slapped, or had something thrown at her OR sometimes or often kicked, bitten, hit with a fist, or hit with something hard OR ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
  • Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
  • Was a household member depressed or mentally ill or did a household member attempt suicide?
  • Did a household member go to prison?
  • Should be Empty: