Therapy Adult New Patient Info

Adult Intake Form
2611 Washington St, Pella, IA 50219

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

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

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

First NameLast Name
Date of Birth

MonthDayYear
Gender

MaleFemale
Address

Street Address/PO Box

Street Address Line 2

CityState / Province

Zip Code
Phone #
Email
example@example.com
Did anyone refer you to Heartland? If yes, who?
Primary Care Physician (PCP)
PCP Phone #
PCP 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 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 timeLoss of interest/not enjoying thingsChange 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 with 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 other symptoms that you may be experiencing:

Inflated self-esteem/grandiosityDecreased need for sleepOverly talkative/Pressured speechRacing thoughts/Flighty 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 are 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 crimeHarassmentOther
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)?
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)
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?
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)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)CocaineMethamphetamineHallucinogens (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
If so, were you successful?

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

YesNo
If yes, where and when did you attend treatment? And was it helpful?
Family and Supportive Relationships
Current situation:

MarriedNever marriedDivorced/SeparatedCohabitatingWidowed
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-timePart-timeUnemployedRetiredFull-time StudentPart-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?
Signature*

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Adult Intake Form

Demographic Information

Primary Insurance Information

Secondary Insurance Information

General Information

Trauma History

Family History

Medical History

Family and Supportive Relationships

Early Development

Education/Employment Information

Legal History