Behavioral Health Intake Form
Client Name:
*
First Name
Last Name
Client Date of Birth:
*
-
Month
-
Day
Year
Date
Client Gender:
Please Select
Male
Female
Transgender
Client Social Security Number:
Client/Guardian Phone Number:
*
Please enter a valid phone number.
Client Marital Status:
Please Select
Never Married
Partnered
Married
Separated
Divorced
Widowed
Contact Email
*
example@example.com
Client Current Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you currently:
Working
Student
Unemployed
Disabled
Retired
If Student, Please list school below
Referred By:
Insurance Company
Internet Search
Word of Mouth
Advertisement
Other
Were you referred by someone from Peter James? If so please let us know who:
First Name
Last Name
Primary Insurance Company
*
Please Select
Caresource
Buckeye Health Plan
United Health Community Plan
Molina Healthcare
AmeriHealth Caritas
Anthem Blue Cross Blue Shield
Humana Healthy Horizons
Aetna Better Health
Other Medicaid Provider
Primary Insurance Identification Number
Insurance Identification Number
Are you currently receiving psychological services, professional counseling, psychiatric services, or any other mental health services?
*
Please Select
yes
no
Have you been psychiatrically hospitalized in the past?
Please Select
yes
no
If yes, please list dates and locations:
General Health information
How is your physical health at the present time?
*
Poor
Unsatisfactory
Satisfactory
Good
Very Good
How would you describe your sleep habit?
Please Select
Sleep too much
Sleep too little
Poor Quality
Disturbing Dreams
Other
If selected other, please explain:
Check the issues below that apply to you.
*
Depressed mood
Racing thoughts
Excessive worry
Unable to enjoy activities
Impulsivity
Anxiety attacks
Sleep pattern disturbance
Increase risky behavior
Avoidance
Loss of interest
Increased libido
Hallucinations
Concentration/forgetfulness
Decrease need for sleep
Suspiciousness
Change in appetite
Excessive energy
Excessive guilt
Increased irritability
Fatigue
Crying spells
Decreased libido
Other
Have you ever had feelings or thoughts that you didn't want to live?
*
Yes
No
When was the last time you had thoughts of dying?
*
Do you currently feel that you don't want to live?
*
Yes
No
How often do you have these thoughts?
*
On a scale of 1 to 10, (ten being strongest) how strong is your desire to kill yourself currently?
*
Weak
1
2
3
4
5
6
7
8
9
Strong
10
1 is Weak, 10 is Strong
Medical History
Are you currently taking any psychiatric prescription medication? (If yes, please list them)
Do you have any allergies? (If yes, please list them)
List all current prescription medications and how often you take them
If you have ever taken any of the following medications, please indicate the dates and daily dosage.
Rows
Have you ever taken it?
Dates
Dosage
Side Effects?
Prozac (fluoxetine)
Zoloft (sertraline)
Luvox (fluvoxamine)
Paxil (paroxetine)
Celexa (citalopram)
Lexapro (escitalopram)
Effexor (venlafaxine)
Cymbalta (duloxetine)
Wellbutrin(bupropion)
Remeron (mirtazapine)
Serzone (nefazodone)
Anafranil (clomipramine)
Pamelor (nortrptyline)
Tofranil (imipramine)
Elavil (amitriptyline)
Tegretol (carbamazepine)
Lithium
Depakote (valproate)
Lamictal (lamotrigine)
Tegretol (carbamazepine)
Topamax (topiramate)
Seroquel (quetiapine)
Zyprexa (olanzepine)
Geodon (ziprasidone)
Abilify (aripiprazole)
Clozaril (clozapine)
Haldol (haloperidol)
Prolixin (fluphenazine)
Risperdal (risperidone)
Ambien (zolpidem)
Sonata (zaleplon)
Rozerem (ramelteon)
Restoril (temazepam)
Desyrel (trazodone)
Adderall (amphetamine)
Concerta (methylphenidate)
Ritalin (methylphenidate)
Strattera (atomoxetine)
Xanax (alprazolam)
Ativan (lorazepam)
Klonopin (clonazepam)
Valium (diazepam)
Tranxene (clorazepate)
Buspar (buspirone)
Other medications?
Check if you have ever tried the following:
Methamphetamine
Cocaine
Stimulants (pills)
Heroin
LSD or Hallucinogens
Marijuana
Pain killers (not as prescribed)
Methadone
Tranquilizer/sleeping pills
Alcohol
Ecstasy
Other
Family Background and Psychiatric History
Has anyone in your family been diagnosed with or treated for:
*
Bipolar disorder
Depression
Anxiety
Anger
Suicide
Schizophrenia
Post-traumatic stress
Alcoholabuse
Other
Has any family member been treated with a psychiatric medication? If yes, who was treated, what medications did they take, and how effective was the treatment?
Did your parents divorce?
Yes
No
Do you have a history of being abused emotionally, sexually, physically or by neglect? If yes, please describe when, where and by whom.
Personal History
Have you ever been arrested?
Yes
No
Additional information
Emergency Contact
*
First Name
Last Name
Emergency Phone Number
*
Records released pursuant to this authorization may inclide information concerning testing or diagnos
*
yes, I agree and look forward to having packet of information.
no, I would like further information prior to assessment.
Release of Information
Please select one of the following options: I am giving informed consent of assessment, treatment, and general services as client or guardian.
*
Yes
No
Please select one of the following options: About telehealth services:
*
Yes, I give consent to services including Telehealth
Yes, I give consent to services but do not wish to give consent for telehealth
Acknowledgement of Clients Rights and Confidentiality
*
Yes
No
I would like more information
By signing this document, I agree to the following documents that will be presented by the Therapeutic Behavioral Specialist upon beginning treatment. 1. Informed consent of assessment and treatment. 2. Understanding of privacy practices 3. Telehealth consent 4. Authorization to Bill Insurance 5. Release of information 6. Reasonable Transportation Permission
*
yes, I agree and look forward to having packet of information.
no, I would like further information prior to assessment.
Click to Download Client Information Packet
Date
-
Month
-
Day
Year
Date
Signature
*
Guardian Signature (if under age 18)
Submit
Submit
Should be Empty: