Lincoln Psychiatric Group Intake Form
Name
*
First Name
Last Name
Preferred Name
Date of Birth
*
-
Month
-
Day
Year
Date
What kind of services are you looking for?
*
Psych Evaluation (one-time visit)
Medication management
Medication management for Children (ages 7-18)
Spravato/Ketamine (nasal spray)
Counseling
Counseling for Children (ages 6-18)
Other
can you tell us a little more on what you need?
*
Is there a provider and/or counselor you had in mind?
Assigned Sex At Birth
*
Male
Female
Preferred Gender
Male
Female
Non-Binary
Other
Phone Number
*
If this is not the patient's number, then who will we be speaking to?
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Person
*
First Name
Last Name
Relationship to the patient
*
Please Select
Father
Mother
Brother
Sister
Relatives
Guardian
Friend
Spouse
Primary Phone Number of Emergency Contact Person
*
Please enter a valid phone number.
Secondary Phone Number of Emergency Contact Person
Please enter a valid phone number.
Do you know of anyone who currently sees a provider here at Lincoln Psychiatric Group?
Yes
No
If so, who and how are they related to you?
Billing
Will you be paying out-of-pocket or with insurance?
*
Out-Of-Pocket
I am Insured
Primary Insurance (Required. If not applicable, type "Self" in Company field and continue to Emergency Contact.)
*
Primary Insurance Front & Back
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Secondary Insurance
Secondary Insurance Front & Back
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Billing information (if different from patient)
Pharmacy/Primary Care Doctor
Preferred Pharmacy
Pharmacy Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pharmacy Phone Number
Pharmacy Fax Number
Do you have a primary Care Doctor?
*
Yes
No
Name of Doctor
Name of doctor office
Office Number
Please enter a valid phone number.
Office Address
Street Address
City
State / Province
Postal / Zip Code
Mental Health Status/History
Height for Medication Management Purposes
*
Weight for Medication Management Purposes
*
Please select the following symptoms you are currently experiencing (Please select "YES" and its corresponding severity if applicable)
*
YES
Mild
Moderate
Severe
NO
Aggression
Agitation
Anger
Anxiety
Appetite change
Change in libido
Crying/tearful
Cyber addiction
Depression
Disorientation
Difficulty getting out of bed
Difficulty making decisions
Distractibility
Eating disorder
Judgment errors
Loneliness
Loss of interest in activities
Nightmares
Paranoia
Hallucinations (seeing or hearing things that others don't)
Do you have difficulty sleeping?
*
Yes
No
If so, what difficulties are you having?
*
Difficulty falling asleep
Difficulty staying asleep
Early morning waking
Less than 5 hours of sleep per night
More than 9 hours of sleep per night
Other
Are you having suicidal thoughts (even if you would never act on them)?
*
Yes
No
If so, how often?
*
Rarely
Some days
Most days
Everyday
Do you ever feel like acting on these thoughts?
*
Never
Rarely
Some days
Most days
Everyday
Are you having any other problems not listed above? If so, please describe your SYMPTOMS and how the problem is affecting your life. Do not list any medical or psychiatric diagnoses here.
Pharmacy Fax Number
Have you received any counseling or medication management in the past?
*
Yes
No
If yes, please tell us the reason and when.
*
Social History
*
Family Psychiatric History (Do you have a blood relative who was diagnosed with any of the following?)
Bipolar disorder
Suicide attempts or completions
Schizophrenia
Post-traumatic stress
Alcohol or drug abuse
Depression
Anxiety
ADHD
I'm adopted and do not know my history
Other
Are you currently taking any psychiatric medications?
*
Yes
No
If yes, please tell us the medication name, purpose, and the frequency.
*
Who's prescribing these medication?
Have you taken psychiatric medications in the past?
*
Yes
No
If yes, please look through this list of medications and tell us what you have taken. (please answer all 5 questions for each medication that you have taken.) Our providers will not see you if you fail to complete this section of the form
Have you taken this medication
Last Taken? (MM/YYYY)
Did you take for less then 6weeks?
Dose
Did it help?
Side effects? What were they?
Agomelatine (Valdoxan)
less then 6 weeks
more then 6 weeks
Yes
No
Alprazolam (Xanax)
less then 6 weeks
more then 6 weeks
Yes
No
Amitriptyline (Elavil)
less then 6 weeks
more then 6 weeks
Yes
No
Amoxapine (Asendin)
less then 6 weeks
more then 6 weeks
Yes
No
Amphetamine (Adderall)
less then 6 weeks
more then 6 weeks
Yes
No
Aripiprazole (Abilify)
less then 6 weeks
more then 6 weeks
Yes
No
Armodafinil (Nuvigil)
less then 6 weeks
more then 6 weeks
Yes
No
Asanapine (Saphris)
less then 6 weeks
more then 6 weeks
Yes
No
Atomoxetine (Strattera)
less then 6 weeks
more then 6 weeks
Yes
No
Brexpiprazole (Rexulit)
less then 6 weeks
more then 6 weeks
Yes
No
Bupropion (Wellbutrin)
less then 6 weeks
more then 6 weeks
Yes
No
Buspirone (Buspar)
less then 6 weeks
more then 6 weeks
Yes
No
Caplyta (Lumateperone)
less then 6 weeks
more then 6 weeks
Yes
No
Carbamazepine (Tegretol)
less then 6 weeks
more then 6 weeks
Yes
No
Cariprazine (Vraylar)
less then 6 weeks
more then 6 weeks
Yes
No
Chlordiazepoxide (Librium)
less then 6 weeks
more then 6 weeks
Yes
No
Chlorpromazine (Thorazine)
less then 6 weeks
more then 6 weeks
Yes
No
Citalopram (Celexa)
less then 6 weeks
more then 6 weeks
Yes
No
Clonazepam (Klonopin
less then 6 weeks
more then 6 weeks
Yes
No
Clomipramine (tofranil)
less then 6 weeks
more then 6 weeks
Yes
No
Clozapine (Clozaril)
less then 6 weeks
more then 6 weeks
Yes
No
Desipramine (Noripramin)
less then 6 weeks
more then 6 weeks
Yes
No
Desmethyphenidate (Focalin)
less then 6 weeks
more then 6 weeks
Yes
No
Desvenlafaxine (Pristiq)
less then 6 weeks
more then 6 weeks
Yes
No
Dexamphetamine (Dexedrine)
less then 6 weeks
more then 6 weeks
Yes
No
Diazepam (Valium)
less then 6 weeks
more then 6 weeks
Yes
No
Doxepin (Sinequan)
less then 6 weeks
more then 6 weeks
Yes
No
Doxepin (Silenor)
less then 6 weeks
more then 6 weeks
Yes
No
Escitalopram (Lexapro)
less then 6 weeks
more then 6 weeks
Yes
No
Estazolam (Prosom)
less then 6 weeks
more then 6 weeks
Yes
No
Eszopiclone (Lunesta)
less then 6 weeks
more then 6 weeks
Yes
No
Fluoxetine (Luvox)
less then 6 weeks
more then 6 weeks
Yes
No
Gabapentin (Neurontin)
less then 6 weeks
more then 6 weeks
Yes
No
Imipramine (Tofranil)
less then 6 weeks
more then 6 weeks
Yes
No
Isocarboxazid (Marplan)
less then 6 weeks
more then 6 weeks
Yes
No
Levomilnacipram (Fetzima)
less then 6 weeks
more then 6 weeks
Yes
No
Lorazepam (Ativan)
less then 6 weeks
more then 6 weeks
Yes
No
Lurasidone (Latuda)
less then 6 weeks
more then 6 weeks
Yes
No
Methylphenidate (Ritalin, Cpnserta, Daytrana, Quillivant/
less then 6 weeks
more then 6 weeks
Yes
No
Milnacipran (Savella)
less then 6 weeks
more then 6 weeks
Yes
No
Mirtazapine (Remeron)
less then 6 weeks
more then 6 weeks
Yes
No
Modafinil (Prodigal)
less then 6 weeks
more then 6 weeks
Yes
No
Mydayis
less then 6 weeks
more then 6 weeks
Yes
No
Negazodone (Serzone)
less then 6 weeks
more then 6 weeks
Yes
No
Nortriptyline (Pamelor)
less then 6 weeks
more then 6 weeks
Yes
No
Haloperidol (Haldol)
less then 6 weeks
more then 6 weeks
Yes
No
Lamotrigine (Lamictal)
less then 6 weeks
more then 6 weeks
Yes
No
Liothryonine (Cytomel)
less then 6 weeks
more then 6 weeks
Yes
No
Lisdexamfetamine (Vyvanse)
less then 6 weeks
more then 6 weeks
Yes
No
Lithium
less then 6 weeks
more then 6 weeks
Yes
No
Olanzapine (Zyprexa)
less then 6 weeks
more then 6 weeks
Yes
No
Oxazepam (Serax)
less then 6 weeks
more then 6 weeks
Yes
No
Pailperdone (Invega)
less then 6 weeks
more then 6 weeks
Yes
No
Paroxetine (Paxil)
less then 6 weeks
more then 6 weeks
Yes
No
Perphenazine (Trilafon)
less then 6 weeks
more then 6 weeks
Yes
No
Phenelzine (Nardil)
less then 6 weeks
more then 6 weeks
Yes
No
Pramipexole (Mirapex)
less then 6 weeks
more then 6 weeks
Yes
No
Protriptyline (Vivacity)
less then 6 weeks
more then 6 weeks
Yes
No
Quetiaphine (Seroquel)
less then 6 weeks
more then 6 weeks
Yes
No
Ramelteon (Rozerem)
less then 6 weeks
more then 6 weeks
Yes
No
Risperidone (Risperdal)
less then 6 weeks
more then 6 weeks
Yes
No
Ropinirole (Requip)
less then 6 weeks
more then 6 weeks
Yes
No
Selegiline (Emsame patch)
less then 6 weeks
more then 6 weeks
Yes
No
Sertraline (Zoloft)
less then 6 weeks
more then 6 weeks
Yes
No
Suvorexant (Belsomra)
less then 6 weeks
more then 6 weeks
Yes
No
Temazepam (Restoril)
less then 6 weeks
more then 6 weeks
Yes
No
Thioridazine (Mellaril)
less then 6 weeks
more then 6 weeks
Yes
No
Topiramate (Topamax)
less then 6 weeks
more then 6 weeks
Yes
No
Tranylcypromine (Parnate)
less then 6 weeks
more then 6 weeks
Yes
No
Trazodone (Desyrel)
less then 6 weeks
more then 6 weeks
Yes
No
Triazolam (Halcyon)
less then 6 weeks
more then 6 weeks
Yes
No
Trifluoperazine (Stelline)
less then 6 weeks
more then 6 weeks
Yes
No
Trimipramine (Surmontil)
less then 6 weeks
more then 6 weeks
Yes
No
Valproid Acid (Depakote)
less then 6 weeks
more then 6 weeks
Yes
No
Varenicline (Chantix)
less then 6 weeks
more then 6 weeks
Yes
No
Vilazodone (Viibyrd)
less then 6 weeks
more then 6 weeks
Yes
No
Vorteoxetine (Trintellix)
less then 6 weeks
more then 6 weeks
Yes
No
Zaleplon (Sonata)
less then 6 weeks
more then 6 weeks
Yes
No
Ziprasidone (Geodon)
less then 6 weeks
more then 6 weeks
Yes
No
Zolpidem (Ambien)
less then 6 weeks
more then 6 weeks
Yes
No
Vistaril (Hydroxyzine)
less then 6 weeks
more then 6 weeks
Yes
No
Propranolol
less then 6 weeks
more then 6 weeks
Yes
No
Quvivq
less then 6 weeks
more then 6 weeks
Yes
No
Qelbree
less then 6 weeks
more then 6 weeks
Yes
No
Please Let us know if you have tried any of the treatments/therapies below
Check if ever receiver
Last received / used (MM/YYYY)
Type of stimulation
Number of sessions
did it help?
Side effects? What were they?
ECT
1 side
2 sides
doesn't apply
Yes
No
TMS
1 side
2 sides
doesn't apply
Yes
No
t-DCS
1 side
2 sides
doesn't apply
Yes
No
VNS
1 side
2 sides
doesn't apply
Yes
No
Ketamine Infusion
1 side
2 sides
doesn't apply
Yes
No
S-ketamine Intranasal
1 side
2 sides
doesn't apply
Yes
No
Light Therapy
1 side
2 sides
doesn't apply
Yes
No
Psychotherapy (CBT)
1 side
2 sides
doesn't apply
Yes
No
Psychotherapy (DBT)
1 side
2 sides
doesn't apply
Yes
No
Psychotherapy (Other)
1 side
2 sides
doesn't apply
Yes
No
EMDR
1 side
2 sides
doesn't apply
Yes
No
PHQ-9 - Answer these questions based on how you've felt during the past 2 weeks
*
Not At All
Several Days
More Than Half The Days
Nearly Every Day
Little Interest or pleasure in doing things.
Feeling down, depressed, or hopeless.
Trouble falling or staying asleep, or sleeping too much.
Feeling tired or having little energy.
Poor appetite or overeating
Feeling bad about yourself - or that you are a failure or have let yourself or your family down.
Trouble concentrating on things, such as reading the newspaper or watching television.
Moving or speaking so slowly that other people could have notices. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual.
Thoughts that you would be better off dead, or of hurting yourself in some way.
GAD-7 - Answer these questions based on how you've felt the past two weeks
*
Not At All
Several Days
More Than Half The Days
Nearly Every Day
Feeling nervous, anxious, or on edge.
Not being able to stop or control worrying.
Worrying too much about different things.
Trouble relaxing.
Being so restless that it's hard to sit still.
Becoming easily annoyed or irritable.
Feeling afraid as if something awful might happen.
Medical History
Are you Pregnant or Breast Feeding?
*
No or Does Not Apply
Planning
Currently Pregnant
Breast Feeding
Had a baby within the past year
Do you have any allergies?
*
Yes
No
If yes, please tell us what allergies you have.
*
Are you or were you a smoker, vaper, or chewer?
*
Current
Past
Never
What products did/do you use? How much? How often?
*
Do you drink alcohol? Please tell us how often and how much you drink on those occasions.
*
Never
1 day a week
2-3 days a week
4-7 days a week
1-2 drinks per occasion
3-4 drinks per occasion
4 or more drinks per occasion
What type of alcohol do you typically drink?
*
Beer
Wine
Liquor
Please list any current or past illegal drug use. If not applicable, please type, "NA".
*
Have you ever been in treatment for substance use?
*
Yes
No
Please share what substance, type and frequency of treatment, if you completed treatment and the last time the substance was used.
*
Have you or a blood relative ever been diagnosed with any of the following?
*
Personal History
Family History
I was adopted and do not know my medical history.
Not Applicable
Diabetes
High blood pressure
High Cholesterol
Obesity
COPD
Asthma
Cardiovascular disease
Thyroid Disease
GERD
Sleep apnea
Glaucoma
Seizures
Fibromyalgia
Stroke
Head injury
Hepatitis
Dementia
Kidney disease
Liver disease
Lupus
Migraines
Other
Signature
*
Date Signed
*
/
Month
/
Day
Year
Date
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