Psychiatry Intake Form
2611 Washington St, Pella, IA 50219 // 1701 48th St, Suite 110, West Des Moines, IA 50266
Name
DOB
Gender
Male
Female
Other
Preferred Name To Be Used
Address
City, State, Zip
Phone Number
Please enter a valid phone number.
The above phone number is my...
Cell/Mobile
Home
Work
Email Address
Are you able to make your own legal/medical decisions?
Yes
No
If No, who is your legal guardian?
Legal guardian relationship to patient
Marital Status
Single
Married
Divorced
Widow
Life Partner
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Phone Number
Primary Insurance Provider
Primary Insurance ID #
Primary Insurance Group #
Primary Insurance Policy Holder
Primary Insurace Policy Holder's DOB
Primary Insurance Policy Holder's employer
Secondary Insurance Provider
Seconary Insurance ID #
Secondary Insurance Group #
Secondary Insurance Policy Holder
Secondary Insurance Policy Holder's DOB
Policy Holder's employer
Military Service?
Yes
No
If yes to Military Service, what branch did you serve in?
How many years did you serve in the Military?
Employment Status and Education
Employment Status
Employed (full time, part time, self)
Unemployed
Retired
Disabled
Occupation
Company you work for
Highest level of education
High School Diploma
GED
College Degree (Please indicate the highest level of degree in the "Other" below.)
Other
Reason for today's visit
Current Medications - please include all over-the-counter, supplements, and vitamins
Please list medication name, dose and frequency below.
Current Pharmacy
City the pharmacy is in
Indicate here if you have NO known medication or food allergies.
I don't know of any personal allergies to medication or food.
Please list the medication/food you are allergic to and how you react to it.
Do you have an allergy to Latex?
Yes
No
Psychiatric History
Past and Current Mental Health Diagnosis - (Please include onset with diagnosis.)
Family History of Mental Health
Name of Previous Provider
Organization/location of Previous Provider
Have you ever been admitted to an inpatient psych facility or hospital in the past?
Yes
No
If yes, when was the last admission?
What were you admitted for?
What facility or location were you admitted to?
Have you ever attempted suicide?
Yes
No
If yes, when was your last attempt?
What Method/means did you use?
Did you seek treatment for your attempt?
Yes
No
Have you attempted suicide multiple times?
Yes
No
Any thoughts or actions of self harm (cutting, burning, hurting self for emotional relief or purpose)?
Yes
No
If yes, when was the last time you self-harmed?
Method of self-harm?
Have you ever had any thoughts of hurting/harming anyone else?
Yes
No
If yes, have you ever attempted to harm anyone?
Yes
No
Did you have a specific person you've wanted to hurt?
Yes
No
If yes, who and in what way did you want to harm/kill them?
Have you received any other types of treatment for your mental health (ETC treatments, TMS, talk therapy/counseling)?
Yes
No
If yes, please state what, when and where treatment was received.
Substance Use
Do you consume alcohol?
Yes
No
If yes, how many times per week do you consume alcohol?
How many drinks do you consume at one time?
Do you use any nicotine/tobacco products?
Yes
No
If yes, what product form (cigarettes, vape, chew, gum, patch) and how much do you use daily?
PAST SUBSTANCE USE - Please check which substances you have USED IN THE PAST.
Marijuana/THC/CBD (edibles, oil, smoke)
Cocaine
Methamphetamine
Hallucinogens (LSD/PCP)
Acid
Kratom
Ecstasy/Molly/MDMA
Non prescription Steroids
Inhalants
Heroin
Mushrooms
Medications not prescribed to you
Stimulants (ie: Adderall)
Benzodiazepine (ie: Ativan)
Opioids/Narcotics (ie: Oxy)
Barbiturates
Sleep Aids (ie: Ambien)
Other
CURRENT SUBSTANCE USE - Please check which substances you are CURRENTLY using.
Marijuana/THC/CBD (edibles, oil, smoke)
Cocaine
Methamphetamine
Hallucinogens (LSD/PCP)
Acid
Kratom
Ecstasy/Molly/MDMA
Non prescription Steroids
Inhalants
Heroin
Mushrooms
Medications not prescribed to you
Stimulants (ie: Adderall)
Benzodiazepine (ie: Ativan)
Opioids/Narcotics (ie: Oxy)
Barbiturates
Sleep Aids (ie: Ambien)
Other
Have you ever tried to reduce your alcohol/tobacco/drug use?
Yes
No
Have you been a victim of abuse or neglect?
Yes
No
What type of abuse or neglect have you been a victim of?
Physical
Sexual
Emotional
Other
Have you been the purpetrator of abuse or neglect?
Yes
No
If yes, what kind of abuse did you inflict on someone else?
Physical
Sexual
Emotional
Other
Other trauma?
Car accident
Death/Serious Illness of a loved one
Victim of or witness to a crime
Harassment
Other
Medical History
Primary Care Physician
Organization or location of primary care physicain
Do you have specialty providers and/or other providers that you currently receive care from?
Yes
No
Please provide the name, specialty and organization/location of other physicians.
Current Medical Diagnosis
How would you describe your current sleep?
How many hours, on average, are you sleeping at night?
Do you currently take any naps?
Yes
No
Any changes in weight or appetite?
Yes
No
If yes, please decribe.
Have you ever been diagnosed with an eating disorder?
Yes
No
If yes, please describe.
Have you fallen in the last 6 months?
Yes
No
Any dizziness or lightheadedness upon standing?
Yes
No
Legal History
Any current legal problems?
Yes
No
If yes, please describe.
Name of Patient
Signature
Clear
Date
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