Adult Intake

Adult Intake
Name

FirstLast
DOB

MonthDayYear
Preferred Name
Gender Identity
Preferred Pronouns
Preferred Pronouns
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Insurance Company
If your insurance is not listed, we are out-of-network! Services will be private pay. Evaluations are $4000; Therapy is $175/session.
Member ID/Policy Number
Group Number
Secondary Insurance
Secondary Insurance
If your insurance is not listed, we are out-of-network! Services will be private pay. Evaluations are $4000; Therapy is $175/session.
Member ID/Policy Number
Group Number
Who/what place referred you to our office?
Referring Provider/Clinic
Name
Presenting Concerns/Reason for Service

School/Employment History
Occupation
Employer
What do you enjoy about your occupation/employer?
Are there any parts of your job that are difficult relating to the reason for service?
Current Education Level
Are you a student?
What school/college?
What grade?
What do/did you enjoy most in school (subjects, activities)?
What is/was most difficult in school (subjects, activities)?

Rows	Yes	No	Unknown
Fertility issues, difficulties conceiving
Abnormal weight gain
Bleeding
Anemia
Alcohol or drug use
Bed rest
Anxiety/depression
Significant injury
Abuse (physical, emotional, verbal, sexual)

Rows	Past	Present
Allergies
Asthma
Anemia
Serious head injury or concussion(s)
Seizure(s) or epilepsy
Heart problems
Vision problems
Hearing problems
Headaches or migraines
Kidney problems
Hypothyroid (underactive)
Hyperthyroid (overactive)
Diabetes (type 1)
Diabetes (type 2)
Cancer
High blood pressure
Low blood pressure
Broken bones
Significant surgery
Speech therapy
Occupational therapy
Emotional abuse
Physical abuse
Sexual abuse
Verbal abuse

Rows	excellent	very good	good	fair	poor
In general, would you say your health is...
In general, would you say your quality of life is...
In general, how would you rate your physical health?
In general, how would you rate your mental health, including your mood and ability to think?
In general, how would you rate your satisfaction with your social activities and relationships?
In general, please rate how well you carry out your social activities and roles (activities at home, at work and in your community, and responsibilities as a parent, child, spouse, employee, friend).
To what extent are you able to carry out your everyday activities such as walking, climbing stairs, carrying groceries, or moving a chair?

School/Employment History

Rows	Yes	If yes, please explain.
Are you currently involved in any legal difficulties?
Have you had any legal problems in the past?
Do you identify with any specific religious, spiritual or cultural affiliation?
Do you participate in any religious, spiritual or cultural practices?

Rows	Past	Present	Never
Prolonged periods of sadness/depression
Excessive anxiety
Panic or anxiety attacks
Compulsive habits or rituals
Eating or appetite concerns
Sleep difficulties or concerns
Manic episodes
Thoughts of suicide
Self-harming actions
Suicide attempt(s)
Attention-deficit hyperactivity disorder
Learning disabilities
Psychotic episode(s)
Autism spectrum disorder
Pervasive developmental disorder
Bipolar disorder
Obsessive-compulsive disorder
Mood disorder
Have you wished that you were dead?
Have you wished that you could go to sleep and not wake up?
Have you given thought to how you could kill yourself?
Have you worked out details of how to kill yourself?
Have you done anything, started to do anything, or prepared to do anything to end your life?
Have you ever talked to someone (I.e., friend, parent, therapist about suicidal thoughts or behaviors)?