Capital Health Group Intake Form

New Patient Intake Form
Name
Date

MonthDayYear
Preferred Name
Gender
Sexual orientation
Gender identity
Address
Email Address
example@example.com
Okay to use?
Home Phone
Please enter your home phoneFormat: (000) 000-0000.
Okay to leave message?
Cell Phone
Please enter your cell phoneFormat: (000) 000-0000.
Okay to leave message?
All clients will be sent a text message and email for appointment reminders three days prior to scheduled appt.
Emergency Contact Information:
Name
Relationship
Address
Home Phone
Please enter your home phone Format: (000) 000-0000.
Cell Phone
Please enter your cell phoneFormat: (000) 000-0000.
Work Phone
Please enter your work phoneFormat: (000) 000-0000.
IF ANOTHER PERSON IS RESPONSIBLE FOR CHARGES:
Name
Relationship
Address
Home Phone
Please add home phone numberFormat: (000) 000-0000.
Cell Phone
Please add cell phone numberFormat: (000) 000-0000.
Work Phone
Please add cell phone numberFormat: (000) 000-0000.
How did you hear about Capital Health Group?
Why are you currently seeking treatment?
Please describe the symptoms you are experiencing:
When did they start?
Were your symptoms sudden or gradual?
What makes the symptoms better or worse?
Were you formally diagnosed? Date and by whom?
How are your daily symptoms interfering with your daily routine?
Does it interfere with:
Sleep: How many hours do you sleep per night?
Any problem with (check ALL that apply):
Sleep Habits (check ALL that apply):
Appetite (check ALL that apply):
Eating Behaviors (check ALL that apply):
Any weight changes (Yes or No):
Highest Weight
Lowest Weight
Energy Level
PSYCHIATRIC HISTORY
Please check ALL that apply
Suicide: History of Suicidal Ideation
Number of attempts in lifetime:
History of Self-Injury
PSYCHIATRIC HOSPITALIZATION HISTORY
Have you ever been hospitalization in a psychiatric facility?
If Yes, Name of Hospital(s)
Dates of Hospitalization
Reason for hospitalizations
What meds have you trialed? List your response and duration of time used? (EX. Zoloft-ineffective, felt worse, 90 days)
1
2
3
4
5
6
Past Medical History - Do you now or have you ever had the follow (check ALL that apply):
Any other medical and/or surgical history (Please list surgical history and dates):

Current Medications (include nutritional supplements, herbal supplements and over-the-counter medications):

Rows	Name of Medication and Approx. Start Date	Dose	Frequency	Reason Prescribed
1
2
3
4
5

Allergies (medication and food):
Please provide pharmacy of choice and include address and phone number:

Chemical Use History:

Rows	Method of use and amount	Frequency of use	Age of first use	Age of last use	Used in last 48 hours?	Used in last 30 days?
Alcohol
Barbiturates
Valium/Librium
Cocaine/Crack
Heroin/Opiates

Please enter ALL that apply

Rows	Method of use and amount	Frequency of use	Age of first use	Used in last 48 hours?	Used in last 30 days?
Marijuana
PCP/LSD/Mescaline
Inhalants
Caffeine
Nicotine
Over the counter
Prescription drugs
Other drugs

Have you ever been treated for substance abuse?
Have you ever been treated for any of the follow as a result of your drug or alcohol use (check ALL that apply):
Are you on Suboxone or Methadone?
FAMILY HISTORY: Include: Bipolar disorder, Anxiety, Personality Disorders, Substance Abuse, ADHD/ADD, Autism, Depression, Schizophrenia, Suicide Attempts.
Mother
Father
Sister
Brother
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Maternal Grandfather
Trauma History (check ALL that apply):

Former Psychiatrist and Therapist (Please list name, address and phone number)

Rows	Psychiatrist or Therapist Name	Phone Number	Address

SOCIAL HISTORY FOR CHILDREN AND ADOLESCENTS
Who lives at home?
Are parent married?
Are there step-parents involved?
School attended
Grade
IEP in place
Special Ed
Gifted
Other services involved at school?
Aggression at School?
Suspension/Expulsion from school:
Excessive Abscenses
Extracurricular Activites:
SOCIAL HISTORY FOR ADULTS
Who lives in the home
Highest Level of Education
Employment Status
Occupation
Employer:
How long have you had this job?
List current stressors:
ADDITIONAL INFORMATION: Please inform me of any other concerns or pertinent information here:
Please attach any previous assessments or collateral information (i.e psychological evaluation, psychiatric evaluation, discharge summary, etc.)

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Should be Empty:

New Patient Intake Form

PSYCHIATRIC HISTORY

PSYCHIATRIC HOSPITALIZATION HISTORY

FAMILY HISTORY: Include: Bipolar disorder, Anxiety, Personality Disorders, Substance Abuse, ADHD/ADD, Autism, Depression, Schizophrenia, Suicide Attempts.

SOCIAL HISTORY FOR CHILDREN AND ADOLESCENTS

SOCIAL HISTORY FOR ADULTS