Behavioral Health Intake Form

Behavioral Health Intake Form
Date

MonthDayYear
Date
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Date of Birth

MonthDayYear
Date
Gender
Primary Care Physician

First NameLast Name
Current Symptoms

Depressed moodRacing thoughtsExcessive worryUnable to enjoy activitiesImpulsivityAnxiety attacksSleep pattern disturbanceIncrease risky behaviorAvoidanceLoss of interestIncreased libidoHallucinationsConcentration/forgetfulnessDecrease need for sleepSuspiciousnessChange in appetiteExcessive energyExcessive guiltIncreased irritabilityFatigueCrying spellsDecreased libidoOther
Please list recent significant event or problem(s) which you are seeking help?
Have you ever had feelings or thoughts that you didn't want to live?

YesNo
Do you currently feel that you don't want to live?

YesNo
How often do you have these thoughts?
When was the last time you had thoughts of dying?

On a scale of 1 to 10, (ten being strongest) how strong is your desire to kill yourself currently?

	1	2	3	4	5	6	7	8	9	10

1 is Weak, 10 is Strong

	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?

Medical History
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
Do you have any allergies? (If yes, please list them)
For women only:
Psychiatric History:
Do you have a history of being abused emotionally, sexually, physically or by neglect? If yes, please describe.
Outpatient treatment

YesNo
If yes, Please describe when, by whom, and nature of treatment
Psychiatric Hospitalization

YesNo
If yes, Please describe when, by whom, and nature of treatment
Past Psychiatric Medications

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

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

Bipolar disorderDepressionAnxietyAngerSuicideSchizophreniaPost-traumatic stressAlcoholabuseOther
Check if you have ever tried the following

MethamphetamineCocaineStimulants (pills)HeroinLSD or HallucinogensMarijuanaPain killers (not as prescribed)MethadoneTranquilizer/sleeping pillsAlcoholEcstasyOther
How many caffeinated beverages do you drink a day?
Tobacco History
Have you ever smoked cigarettes?

YesNo
How many packs per day?
How many years?
Personal History
Where did you grow up?
Highest grade completed?
Are you currently:

WorkingStudentUnemployedDisabledRetired
Are you currently:

MarriedPartneredDivorcedSingleWidowed
Do you have any children?

YesNo
Please list ages and gender:*
Have you ever been arrested?

YesNo
Do You Have Insurance? Type (State or Employer)? Name of insurance?
Emergency Contact

First NameLast Name
Phone Number

Area CodePhone Number
Signature

Clear
Guardian Signature (if under age 18)

Clear
Should be Empty:

Medical History