Intake Form

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.
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.
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)

	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?

	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:

	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?

	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. *

Clear
(If Under age 18) Guardian Name

First Name Last Name
(If Under age 18) Guardian Signature

Clear
Should be Empty:

Intake Form

Suicide Risk Assessment

Past Medical History

Past Psychiatric History

Possible Tramatic History

Education History

Occupational History

Personal History