Notice of Privacy Practices

Intake Assessment
Name*

First NameLast Name
Today's Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date*

MonthDayYear
Age*
Phone: Home*
Phone: Work*
Phone: Cell*
Which are OK to contact you?*

Home PhoneWork PhoneCell Phone
Occupation*
School*
Grade*
Relationship*

SingleMarried/PartnershipSeparatedDivorceWidowed
Primary Care Physician*
Phone*
Psychiatrist*
Phone*
Case Manager*
Phone*
Emergency Contact*

First NameLast Name
Phone*
Relationship*
Others living in household and their relationship:*
Please describe your reason(s) for seeking treatment at this time (Include time that the problem started).*
Was there a particular event which made these issues or problems surface?*

YesNo
What result(s) do you expect from treatment?*

Please indicate and rate the severity of the following issues or problems you would like to work on in treatment.*

	No Problem	Mild Problem	Moderate Problem	Severe Problem
Depression
Marriage/Relationship Issue
Loneliness
Controlling Stress
Family Conflict
Abuse/Victimization
Eliminating a drug/alcohol problem
Legal Matters
Suicide Attempt History/Ideation
Lack of Friends
Anxiety
Problem Coping
Loss of A Loved One
Behavioral Problems
Financial Problems
Problems at Work/School
Elimination Another Habit (i.e. overspending, over eating, gambling etc.)
Sexual/sexuality Issues

Hospitalizations

(Include name of Medical Center, Date, Reason for hospitalization i.e., Medical/Mental Health/Rehab.)

Hours spent at:*

Do you experience any of the following symptoms? (Please check all that apply)*

Double or Poor VisionDifficulty HearingFaintingConvulsionsDizzinessThyroidParalysisCough/WheezingShortness of BreathPalpitation of HeartAnxiety/Panic AttachesEating DisorderSomatic ComplaintsExperiences of Time LossUnusual Excessive Thirst/Dry MouthIndigestion/Gas/HeartburnBlackoutsSeizuresHeadachesWeakness or TirednessProblems With Memory/Thinking/Concentration or AttentionTrouble SleepingAsthmaSwelling of Hands/FeetPrior Trauma Complex-Abuse/Trauma IncidentNight SweatsAuditory/Visual HallucinationsWeight Gain/Loss
If you checked "Weight Gain/Loss", please indicate # Pounds and Time Period
Sleep Issues:*

Early WakingDifficulty Getting to SleepNot SleepingInterrupted SleepNight TerrorsNightmaresSomatic (i.e. jumping out of sleep with physical symptoms)N/A

Panic Episodes:*

	Frequency	Duration/Time	Last Episode
Episodes

History of Traumatic Brain Injury [TBI]: Coma*
Write N/A if this does not apply
Date

MonthDayYear
Trauma:

Type-1 [Car accident, earthquake]Type-2 [Complex Developmental Trauma]
Child Developmental:*

AbusePhysicalEmotionalSexualWitness to Domestic ViolenceN/A
Adult Incident:*

AbusePhysicalEmotionalSexualWitness to Domestic ViolenceN/A
Family Medical History
Has anyone in your family had a serious medical illness? If so, please explain. *
Write N/A if this does not apply
Has anyone in your family had a psychiatric illness? If so, please explain.*
Write N/A if this does not apply
Substance Abuse/Use
Has anyone in your family had a serious addiction to a substance or problem use that you are aware of? If so, please explain.*
Write N/A if this does not apply

Have you ever used drugs or alcohol? If so please describe below:

Do you have a history of blackouts, seizures or withdrawal symptoms? If yes, please describe below:*
Write N/A if this does not apply
Have you received counseling, mental health treatment or treatment for substance abuse in the past? If yes, please describe:*
Write N/A if this does not apply
Type of treatment:
Are there any compulsive repetitive behaviors or thoughts that are of concern to you and/or the people close to you (i.e. gambling, spending, sexual behavior, use of food, exercise, television watching, hoarding, checking, counting, washing, illness-related, thoughts of harming self or someone else, use or fear of use of obscene language ect.) If yes, please describe:*
Write N/A if this does not apply
Family System
AdoptionFoster CareBiological ParentsOther RelativeGroup Home EnvironmentGrandparents Maternal/PaternalBlended Family/Stepparent/Step of Half Siblings
How would you describe your cultural heritage?*
Please describe your family experience of childhood/adolescence and any significant events.*
Please describe your relationship with your mother: *
Please describe your relationship with your father:*
Please use the space below if you think there may be any other important information about you that you think I may need to know:

Intake Assessment