FFT Helping Others Counseling LLC
Client Intake Form
Name
First Name
Last Name
Date of Birth
/
Month
/
Day
Year
Date
Date of Birth
/
Month
/
Day
Year
Date
Gender
Please Select
Please Select
Male
Female
Primary Care Physician
Primary Care Physician
Current Therapist / Counselor
Current Therapist / Counselor
Therapist's Phone Number
Current Symptoms
Depressed mood
Racing thoughts
Excessive worry
Unable to enjoy activities
Impulsivity
Anxiety attacks
Sleep pattern disturbance
Increase risky behavior
Avoidance
Loss of interes
Excessive energy
Have you ever had feelings or thoughts that you didn't want to live?
Have you ever had feelings or thoughts that you didn't want to live?
Have you ever had feelings or thoughts that you didn't want to live?
Have you ever had feelings or thoughts that you didn't want to live?
Have you ever had feelings or thoughts that you didn't want to live?
Have you ever had feelings or thoughts that you didn't want to live?
Have you ever had feelings or thoughts that you didn't want to live?
Increased libido
Hallucinations
Concentration/forgetfulness
Decrease need for sleep
Suspiciousness
Change in appetite
Excessive energy
Have you ever had feelings or thoughts that you didn't want to live?
Yes
No
Do you currently feel that you don't want to live?
Yes
No
How often do you have these thoughts?
Medical History
Do feel Weak or have no strength to get out of bed or do daily activities?
Do you feel hopeless and/or worthless?
Have you ever tried to kill or harm yourself before?
Do have Strength to carry with life?
Do have a strong or mild feeling to harm yourself or commit suicide ?
When was the last time you had thoughts of dying?
Is there anything that would stop you from killing yourself?
Other
When was the last time you had thoughts of dying?
Current Weigh
Current Height
Current Height
Current medical problems
Past medical problems, nonpsychiatric hospitalization, or surgeries
Psychiatric History:
Outpatient treatment
Yes
No
If yes, Please describe when, by whom, and nature of treatment
Psychiatric Hospitalization
Yes
No
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Past Psychiatric Medications
Past Psychiatric Medications
If you have ever taken any of the following medications, please indicate the dates and daily dosage.
If you have ever taken any of the following medications, please indicate the dates and daily dosage.
Have you ever taken it?
Have you ever been prescribed these medications?
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)
Lithiu
Luvox (fluvoxamine)
Past Psychiatric Medications
Other
Lexapro (escitalopram)
Past Psychiatric Medications
Cymbalta (duloxetine)
Past Psychiatric Medications
Remeron (mirtazapine)
Past Psychiatric Medications
Anafranil (clomipramine)
Past Psychiatric Medications
Pamelor (nortrptyline)
Past Psychiatric Medications
Tofranil (imipramine)
Past Psychiatric Medications
Tegretol (carbamazepine)
Past Psychiatric Medications
Depakote (valproate)
Past Psychiatric Medications
Other
Medications
Date
Dosage
Effects
-
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
Medications
Date
Dosage
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
Tegretol (carbamazepine)
Past medication or current medication
Topamax (topiramate)
Past medication or current medication
Seroquel (quetiapine)
Past medication or current medication
Zyprexa (olanzepine)
Past medication or current medication
Geodon (ziprasidone)
Past medication or current medication
Other
Abilify (aripiprazole)
Past medication or current medication
Clozaril (clozapine)
Past medication or current medication
Klonopin (clonazepam)
Past medication or current medication
Prolixin (fluphenazine)
Past medication or current medication
Risperdal (risperidone)
Past medication or current medication
Ambien (zolpidem)
Past medication or current medication
Xanax (alprazolam)
Past medication or current medication
Rozerem (ramelteon)
Past medication or current medication
Restoril (temazepam)
Past medication or current medication
Strattera (atomoxetine)
Past medication or current medication
Ritalin (methylphenidate)
Past medication or current medication
Concerta (methylphenidate)
Past medication or current medication
Buspar (buspirone)
Past medication or current medication
Other medications?
Family Psychiatric History
Bipolar disorder
Depression
Anxiety
Anger
Suicide
Schizophrenia
Post-traumatic stress
Alcoholabuse
Has anyone in your family been diagnosed with or treated for:
Has anyone in your family been diagnosed with or treated for
Post-traumatic stress
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?
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?
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?
Exercise Level
Do you exercise regularly?
Yes
N
How much time each day do you exercise?
How much time each day do you exercise?
Methamphetamine
Cocaine
Stimulants (pills)
Heroin
LSD or Hallucinogens
Marijuana
Pain killers (not as prescribed)
Methadone
Tranquilizer/sleeping pills
Alcohol
Ecstasy
Check if you have ever tried the following
Alcohol
How many caffeinated beverages do you drink a day?
Tobacco History
Have you ever smoked cigarettes?
Yes
No
How many packs per day?
How many years?
Family Background and Childhood History:
Were you adopted?
Yes
No
Did your parents divorce?
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
Highest grade completed?
Are you currently
Working
Student
Unemployed
Disabled
Retired
Are you currently:
Married
Partnered
Divorced
Single
Widowed
Do you have any children?
Yes
No
Emergency Contact
Emergency Contact
Emergency Contact
Phone Number
Date
/
Month
/
Day
Year
Date
MonthDay
Yea
Yea
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BRIEFLYDESCRIBE THE REASON(S) FOR SEEKING ASSITANCE
REFERAL:
Do you need to be on Sliding Scale to pay for health services? Please provide full explanation and financial situation
By signing this agreement, I understand that this information is true and legitimate to the best of my knowledge. The undersigned reader acknowledges that the information provided is confidential: therefore, reader agrees that this information will not be disclosed without written or verbal consent of party. And that all information here to this documentwill be confidential by the HIPPA Guidelines to FFT Helping Other Counseling LLC and will only be released to theparty andthe case worker. And at the discretion of the party and at the consent of said party released to only government agencies only and proprietaries. The release of anyinformation will be at the permission and the discretion of the Client and Client must sign a release of information to any said party, family, doctor or agency.
Please Select
Yes
No
Signature
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