Adult Intake Form
1701 48th St, Ste 120, West Des Moines, IA 50266
Phone (515) 331-0303 Fax (515) 331-9086
Demographic Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Gender
Male
Female
Address
Street Address/PO Box
Street Address Line 2
City
State / Province
Zip Code
Phone #
Format: (000) 000-0000.
Email
example@example.com
Did anyone refer you to Heartland? If yes, who?
Primary Care Physician (PCP)
PCP Phone #
Format: (000) 000-0000.
PCP Address
Other Physician (i.e. Psychiatrist)
Other Physician Phone #
Format: (000) 000-0000.
Other Physician Address
Emergency Contact
Emergency Contact Relationship to client
Emergeny Contact Phone
Format: (000) 000-0000.
Emergency Contact Alternate Phone
Format: (000) 000-0000.
Primary Insurance Information
Primary Insurance Provider
E.g. Blue Cross, United Healthcare, Wellpoint, Medicare, Aetna, Etc.
Primary Insurance ID #
Primary Insurance Group #
Name of Policy Holder
Policy Holder's DOB
Policy Holder's employer
Secondary Insurance Information
If you do not have a secondary insurance, skip this section
Secondary Insurance Provider
Secondary Insurance ID#
Secondary Insurance Group #
Name of Policy Holder
Policy Holder's DOB
Policy Holder's employer
General Information
Primary reason for scheduling appointment:
Your goals for therapy/what do you want to change?
Please check any symptoms that you may be experiencing:
Sad or unhappy most of the time
Loss of interest/not enjoying things
Change in appetite or weight
Sleeping too much
Not sleeping enough
Feeling restless
Feeling sluggish or slow
Decreased energy/fatigue
Feelings of worthlessness/guilt
Concentration difficulties
Crying spells/cries easily
Decreased motivation
Feeling helpless/hopeless
Excessive anxiety or worry
Feeling on edge
Irritability/anger
Need to please or be liked
Difficulty making decisions
Muscle tension/pain/headaches
Flashbacks
Nightmares
Easily startled
Avoid going places/being with others
Fear of failure/disapproval/rejection
Obsessive/Intrusive thoughts
Please check any Compulsive Behavior symptoms that apply:
Counting
Checking
Hand washing/cleaning
Praying
Other
Please check any Panic or Anxiety symptoms you might have:
Panic or anxiety attacks
Racing heart
Sweating
Trembling
Shortness of breath
Feelings of choking
Chest pain
Nausea
Feeling dizzy
Chills
Numbness/tingling
Feeling detached
Fear of going "crazy"/dying
Please check any other symptoms that you may be experiencing:
Inflated self-esteem/grandiosity
Decreased need for sleep
Overly talkative/Pressured speech
Racing thoughts/Flighty ideas
Distractibility
Increased risk taking behavior
Inattentiveness
Difficulty staying organized
Difficulty following directions
Avoid tasks requiring mental effort
Lose items frequently
Forgetful
Hyperactive/On the go all the time
Fidgety
Impulsive
Restricting eating
Fear of gaining weight
Body image difficulties
Binge eating/Lack of control eating
Compensating for eating (vomiting, over exercising, laxatives)
Suspicious/paranoid of others
Hearing/seeing things others don't
Puzzled about what is real/unreal
Gaps in memory
Feeling your thoughts are controlled
Sexual difficulties (low drive/pain)
Sexual addictions/pornography use
Marital/relationship problems
Self harm (cutting, burning, etc)
Suicidal thoughts/attempts
Are there other concerns (not listed above) you want to discuss?
How have these concerns impacted your daily life? (work, relationships, finances, activities of daily living, health)
What triggered these symptoms and how long ago did they begin?
Past Mental Health Treatment/Psychological Assessment: How have you tried to treat your symptoms?
Rows
When?
Where?
Outcome?
Attempt #1
Attempt #2
Attempt #3
Trauma History
Are you currently living in a safe and stable residence?
Yes
No
Have you been a victim of abuse or neglect?
Yes
No
If yes, what type of abuse did you endure?
Physical
Sexual
Emotional
Other
Have you been the perpetrator of abuse/neglect?
Yes
No
If yes, what type of abuse did you inflict on someone else?
Physical
Sexual
Emotional
Other
Other Traumas:
Car accident
Death/serious illness of a loved one
Victim of/Witnessed a crime
Harassment
Other
If you checked any "Other Traumas" listed above, please explain:
Family History
Does anyone in your immediate or extended family suffer from a mental health issue (substance use, suicide, depression, etc)?
Please Select
Yes
No
Unsure
If yes, explain who and the nature of the problem:
Medical History
Do you have any past or current significant medical concerns/surgical procedures?
Yes
No
If yes, please explain
Current medications (name, dosage, reason for taking)
Have you ever had a head injury, regardless of loss of conciousness (fell as a child, concussion, car accident)?
Yes
No
How many hours of sleep do you get nightly?
How many hours of screen time do you have daily?
How many times per week do you consume alcohol?
How many drinks do you typically consume?
Do you use nicotine?
Please Select
Yes
No
If yes, what form and how much (chew/cigarettes/vaping)?
CURRENT USE. Please check any of the following you are CURRENTLY using.
Marijuana (edibles, olis, smoking)
Cocaine
Methamphetamine
Hallucinogens (LSD, PCP, shrooms)
Ecstasy/Molly
Steroids
Stimulants (Adderall, Ritalin)
Benzos (Xanax,Valium, Ativan)
Inhalants
Heroin
Opioids (Fentanyl, Oxy, Percs)
Other
PAST USE ONLY. Please indicate which of the list below you have ever used anytime IN THE PAST.
Marijuana (edibles, oils, smoking)
Cocaine
Methamphetamine
Hallucinogens (LSD, PCP, shrooms)
Ecstasy/Molly
Steroids
Stimulants (Adderall, Ritalin)
Benzos (Xanax, Valium, Ativan)
Inhalants
Heroin
Opioids (Fentanyl, Oxy, Percs)
Other
Have you ever tried to reduce your alcohol/tobacco/drug use?
Yes
No
If so, were you successful?
Yes
No
Have you ever had prior substance abuse treatment or attended support meetings (AA/NA/CR)?
Yes
No
If yes, where and when did you attend treatment? And was it helpful?
Family and Supportive Relationships
Current situation:
Married
Never married
Divorced/Separated
Cohabitating
Widowed
Please list immediate family members and supportive relationships. Include their name, age, relationship to you (sister/aunt/friend/etc.), quality of relationship (close/distant/fair/etc.), and if they live with you.
Name, Age, Relationship, Quality of Relationship, Live with/don't live with
Spiritual/cultural factors: Do you identify with a religious, spiritual, or cultural group that would be important for us to know about?
Early Development
Any complications with pregnancy or birth (mother had a significant illness/alcohol use/smoked cigarettes/etc.)? If yes, please explain:
Any problems with development or health (failure to thrive/low oxygen/delay in meeting milestones such as walking, talking, reading/etc.)? If yes, please explain:
Education/Employment Information
Highest Grade Level Achieved and Area of Study
Current employment status:
Full-time
Part-time
Unemployed
Retired
Full-time Student
Part-time Student
Current/Most recent position and employer:
How long have you been with this job/company?
Are you currently serving or have you previous served in the military? If yes, when, how long and what branch?
If deployed, when/where/how long?
Legal History
Any past/current involvement with the legal system (custody, shoplifting, DUI, assault, etc)? If so, please explain:
What are your strengths?
What are your weaknesses?
Any other concerns or information you would like to share?
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