Adult Intake Form

Adult Intake Form
2611 Washington St., Pella, IA 50219

Phone (641)-628-9599 Fax: (641) 621-1493

1701 48th St, Ste 110 and 120, West Des Moines, IA 50266

Phone (515) 331-0303 Fax (515) 331-9086
Name

First NameLast Name
Date of Birth
Gender

MaleFemale
Address

Address

Street Address Line 2

CityState / Province

Zip Code
Phone
Email
example@example.com
Did anyone refer you to Heartland? If yes, who?
Primary Insurance Provider
Primary Insurance ID #
Primary Insurance Group #
Primary Insurance Policy Holder
Primary Insurance Policy Holder's DOB
Primary Insurance Policy Holder's employer
Secondary Insurance Provider
Secondary Insurance ID#
Secondary Insurance Group #
Secondary Insurance Policy Holder
Secondary Insurance Policy Holder's DOB
Secondary Policy Holder's employer
Primary Care Physician
Primary Care Physician Phone
Primary Care Physician Address
Other Physician (i.e. Psychiatrist)
Other Physician Phone
Other Physician Address
Emergency Contact
Emergency Contact Relationship to client
Emergeny Contact Phone
Emergency Contact Alternate Phone
Primary reson for scheduling appointment:
Your goals for therapy/what do you want to change?
Compulsive behaviors
Please check any symptoms that you may be experiencing:

Sad or unhappy most of the timeLoss of interest/not enjoying thingsLoss in appetite or weightSleeping too muchNot sleeping enoughFeeling restlessFeeling sluggish or slowDecreased energy/fatigueFeelings of worthlessness/guiltConcentration difficultiesCrying spells/cries easilyDecreased motivationFeeling helpless/hopelessExcessive anxiety or worryFeeling on edgeIrritability/angerNeed to please or be likedDifficulty making decisionsMuscle tension/pain/headachesFlashbacksNightmaresEasily startledAvoid going places/being eith othersFear of failure/disapproval/rejectionObsessive/Intrusive thoughts
Please check any Compulsive Behavior symptoms that apply:

CountingCheckingHand washing/cleaningPrayingOther
Please check any Panic or Anxiety symptoms you might have:

Panic or anxiety attacksRacing heartSweatingTremblingShortness of breathFeelings of chokingChest painNauseaFeeling dizzyChillsNumbness/TinglingFeeling detachedFear of going "crazy"/dying
Please check any symptoms that you may be experiencing:

Inflated self-esteem/grandiosityDecreased need for sleepOverly talkative/Pressured speechRacing thoughts/Flightly ideasDistractibilityIncreased risk taking behaviorInattentivenessDifficulty staying organizedDifficulty following directionsAvoid tasks requiring mental effortLose items frequentlyForgetfulHyperactive/On the go all the timeFidgetyImpulsiveRestricting eatingFear of gaining weightBody image difficultiesBinge eating/Lack of control eatingCompensating for eating (vomiting, over exercising, laxatives)Suspicious/paranoid of othersHearing/seeing things others don'tPuzzled about what is real/unrealGaps in memoryFeeling your thoughts re controlledSexual difficulties (low drive/pain)Sexual addictions/pornography useMarital/relationship problemsSelf 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?

	When?	Where?	Outcome?
Attempt #1
Attempt #2
Attempt #3

Trauma History
Are you currently living in a safe and stable residence?

YesNo
Have you been a victim of abuse or neglect?

YesNo
If yes, what type of abuse did you endure?

PhysicalSexualEmotionalOther
Have you been the perpetrator of abuse/neglect?

YesNo
If yes, what type of abuse did you inflict on someone else?

PhysicalSexualEmotionalOther
Other traumas:

Car accidentDeath/serious illness of a loved oneVictim of/Witnessed a crimeHarassmentIf you have other traumas, please explain:
Family History
Does anyone in your immediate or extended family suffer from a mental health issue (substance use, suicide, depression, etc)?
If yes, explain who and the nature of the problem:
Medical History
Do you have any past or current significant medical concerns/surgical procedures?

YesNo
If yes, please explain
Current medications (name, dosage, reason for taking if more space is needed, use the back)
Have you ever had a head injury, regardless of loss of conciousness (fell as a child, concussion, car accident)?

YesNo
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?
What form and how much (chew/cigarettes/vaping)?
CURRENT USE. Please check any of the following you are CURRENTLY using.

Marijuana (edibles, olis, smoking)CocaineMethamphetamineHallucinogens (LSD, PCP, shrooms)Ecstasy/MollySteroidsStimulants (Adderall, Ritalin)Benzos (Xanax,Valium, Ativan)InhalantsHeroinOpioids (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)CocainMethanphetamineHallucinogens (LSD, PCP, shrooms)Ecstasy/MollySteroidsStimulants (Adderall, Ritalin)Benzos (Xanax, Valium, Ativan)InhalantsHeroinOpioids (Fentanyl, Oxy, Percs)Other
Have you ever tried to reduce your alcohol/tobacco/drug use?

YesNo
Were you successful?

YesNo
Have you ever had prior substance abuse treatment or attended support meetings (AA/NA/CR)?

YesNo
Where and when did you attend treatment? And was it helpful?
Family and Supportive Relationships
Current situation:

MarriedNever marriedDivorced/SeparatedCohabitatingWidowed
Family Members. Please list immediate family members' by name, age, releationship (sister/aunt, etc), quality of relationship, and if they live with you.
Spiritual/cultural factors: Do you indentify 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)? Please explain.
Any problems with development or health (failure to thrive/low oxygen/delay in meeting milestones such as walking, talking, reading)? Please explain.
Education/Employment Information
Highest Grade Level Achieved and Area of Study
Current employment status:

Full TimePart TimeUnemployedRetiredFull Time StudentPart Time Student
Current/Most recent position and employer
How long 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, explain
What are your strengths?
What are your weaknesses?
Any other concerns or information you would like to share?
Signature

Clear
Date

MonthDayYear
Date
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Adult Intake Form

Trauma History

Family History

Medical History

Family and Supportive Relationships

Early Development

Education/Employment Information

Legal History