Intake Form
Please complete all information on this form It may seem long, but most of the questions require only a check, so it will go quickly. You may need to ask family members about the family history. Thank you!
Patient's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
First Name
Last Name
Emergency Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Allergies
*
What allergies do you have, if none, please enter "None"
What are the problem(s) for which you are seeking help?
*
What are your treatment goals?
Current Symptoms Checklist (Check Symptoms you are experiencing)
*
Depressed Mood
Racing Thoughts
Excessive Worry
Unable to Enjoy Activites
Impulsivity
Anxiety Attacks
Crying Spells
Decreased Libido
Sleep Pattern Disturbance
Increase Risky Behavior
Avoidance
Loss of Interest
Increased Libido
Hallucinations
Concentration/ Forgetfulness
Fatigue
Decrease Need for Sleep
Suspiciousness
Change in Appetite
Excessive Energy
Excessive Guilt
Increased Irritability
Not Experiencing Any Symptoms
Other
Suicide Risk Assessment
Have you ever had feelings or thoughts that you didn't want to live?
*
Yes
No
If YES, please answer the following. If NO, please skip to the next section.
Do you currently feel that you don't want to live?
Yes
No
N/A
When was the last time you had thoughts of dying?
IF YES, describe your thoughts
Do you have access to guns or any other weapons?
Yes
No
If YES, please explain.
Past Medical History
List ALL current prescription medications and how often you take them: (if none, write none)
Current over-the-counter medications or supplements:
Current medical problems:
Past medical problems, non-psychiatric hospitalization, or surgeries:
Have you ever had an EKG?
Yes
No
FOR WOMEN ONLY: Date of last menstrual period .
-
Month
-
Day
Year
Date
FOR WOMEN ONLY: Are you currently pregnant or do you think you might be pregnant?
Yes
No
Unknown
Do you have any concerns about your physical health that you would like to discuss with us?
Yes
No
Personal and Family Medical History (Have you are your family experienced the following)
Rows
You
Family
Thyroid Disease
Anemia
Liver Disease
Chronic Fatigue
Kidney Disease
Diabetes
Asthma/Respiratory Problems
Stomach or Intestinal Problems
Cancer
Fibromyalgia
Heart Disease
Epilepsy or seizures
Chronic Pain
High Cholesterol
High Blood pressure
Head Trauma
Liver Problems
Other
Is there any additional personal or family medical history?
Yes
No
If YES, please explain
Past Psychiatric History
Have you had any past psychiatric history?
*
Yes
No
Have you had any past psychiatric outpatient treatment?
*
Yes
No
Have you had any past psychiatric hospitalizations?
*
Yes
No
Have you ever taken any of the following medications?
Rows
Yes
No
Zoloft
Luvox
Paxil
Celexa
Lexapro
Effexor
Cymbalta
Welbutrin
Remeron
Seroquel
Zyprexa
Geodon
Abilify
Ambien
Sonta
Clozaril
Haldol
Prolixin
Risperdal
Adderall
Concerta
Ritalin
Strattera
Xanax
Ativan
Klonopin
Buspar
Valium
Have you or anyone in your family been diagnosed with or treated for:
Rows
You
Family
Bipolar Disorder
Schizophrenia
Depression
PTSD
Anxiety
Alcohol Abuse
Anger
Suicide
Violence
Other Substance Abuse
Has any family member been treated with a psychiatric medication?
*
Yes
No
Have you ever been treated for alcohol or drug use or substance abuse?
*
Yes
No
Have you ever tried the following?
Rows
Yes
No
Methamphetamine
Cocaine Stimulants (pills)
Heroin LSD or Hallucinogens
Marijuana
Pain killers (not as prescribed)
Methadone
Tranquilizer/sleeping pills
Alcohol
Ectasy
Other
Possible Tramatic History
Were you adopted?
Yes
No
Do you have a history of being abused emotionally, sexually, physically or by neglect?
Yes
No
IF YES, please describe when, where and by whom
Education History
What is your highest educational level or degree attained?
*
Grade
High School
College
Masters
Doctorate
Occupational History
Are you currently
*
Working
Student
Unemployed
Disabled
Retired
What is your current Occupation
Have you Ever Served in the Military? If so, what branch?
Personal History
Are you currently
Married
Partnered
Divorced
Single
Widowed
How would you identify your sexual orientation?
Straight/Heterosexual
Lesbian/Gay/Homosexual
Bisexual
Transsexual
Unsure/Questioning
Asexual
Other
Prefer not to answer
Have you ever been arrested?
*
Yes
No
Do you have any pending legal problems?
Yes
No
Do you belong to a particular religion or spiritual group
Yes
No
Do you find your involvement helpful during this illness, or does the involvement make things more difficult or stressful for you?
More Helpful
Stressful
I certify that the above information is true to the best of my knowledge and behalf.
*
(If Under age 18) Guardian Name
First Name
Last Name
(If Under age 18) Guardian Signature
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Submit
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