Behavioral Health Intake Form

Behavioral Health Intake Form
Client Name:*

First NameLast Name
Client Date of Birth:*

MonthDayYear
Date
Client Gender:
Client Social Security Number:
Client/Guardian Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Client Marital Status:
Contact Email*
example@example.com
Client Current Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you currently:
If Student, Please list school below
Referred By:

Other
Were you referred by someone from Peter James? If so please let us know who:

First NameLast Name
Primary Insurance Company*
Primary Insurance Identification Number
Insurance Identification Number
Are you currently receiving psychological services, professional counseling, psychiatric services, or any other mental health services? *
Have you been psychiatrically hospitalized in the past?
If yes, please list dates and locations:
General Health information
How is your physical health at the present time?*
How would you describe your sleep habit?
If selected other, please explain:
Check the issues below that apply to you.*

Other
Have you ever had feelings or thoughts that you didn't want to live?*
When was the last time you had thoughts of dying?*
Do you currently feel that you don't want to live?*
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?*

1

2

3

4

5

6

7

8

9

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:

Other
Family Background and Psychiatric History
Has anyone in your family been diagnosed with or treated for:*

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?
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?
Additional information
Emergency Contact*

First NameLast Name
Emergency Phone Number*
Format: (000) 000-0000.
Records released pursuant to this authorization may inclide information concerning testing or diagnos*
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.*
Please select one of the following options: About telehealth services:*
Acknowledgement of Clients Rights and Confidentiality*
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*
Click to Download Client Information Packet
Date

MonthDayYear
Date
Signature*
Guardian Signature (if under age 18)
Should be Empty:

Behavioral Health Intake Form

General Health information

Medical History

Family Background and Psychiatric History

Personal History

Release of Information