Intake Form

Intake Form

Please complete the entire form. If the questions do not apply, please select N/A or skip the question/section.
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Primary Care Physician

First NameLast Name
Has a previous provider provided treatment for the reason you are wanting to be seen today?
Current Therapist / Counselor

First NameLast Name
Therapist's Phone Number
Format: (000) 000-0000.
Please check below if you are receiving other treatment/services from another provider/specialist:
Please describe the reason you are coming in for an assessment:
Please list the problem(s) which you are seeking help?
Current Symptoms

Other
Have you ever had feelings or thoughts that you didn't want to live?
Do you currently feel that you don't want to live?
How often do you have these thoughts?
When was the last time you had thoughts of dying?
On a scale of 1 to 10, (ten being strongest) how strong is your desire to kill yourself currently?

1

2

3

4

5

6

7

8

9

10

1 is Weak, 10 is Strong

Rows	Yes	No
Do you feel hopeless and/or worthless?
Have you ever tried to kill or harm yourself before?
Is there anything that would stop you from killing yourself?

If you have ever taken any of the following medications, please indicate the dates and daily dosage.

Other medications?
Family Psychiatric History
Has anyone in your family been diagnosed with or treated for:

Other
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?
How much time each day do you exercise?
Check if you have ever tried the following

Other
How many caffeinated beverages do you drink a day?
Tobacco History
Have you ever smoked cigarettes?
How many packs per day?
How many years?
Family Background and Childhood History:
Were you adopted?
Where did you grow up?
List your siblings and their ages:
Did your parents divorce?
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:
Are you currently:
Do you have any children?
Please list ages and gender:
Have you ever been arrested?
Additional information
Emergency Contact

First NameLast Name
Phone Number
Format: (000) 000-0000.
Date

MonthDayYear
Date
Signature
Guardian Signature (if under age 18)
Should be Empty:

Medical History