Mental Health Intake Form
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Preferred Pharmacy (Name & Location)
How Did You Hear About Us?
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Male
Female
Other
Who Do You Live With?
Relationship History
Single
Partnered
Married
Divorced
Widowed
Other
How would you identify your sexual orientation?
Straight / Heterosexual
Lesbian / Gay / Homosexual
Bisexual
Transsexual
Unsure / Questioning
Asexual
Prefer Not To Say
Other
Highest Level of Education
Occupation
Emergency Contact Person
First Name
Last Name
Relationship to the patient
Please Select
Father
Mother
Brother
Sister
Relatives
Guardian
Friend
Phone Number of Emergency Contact
Please enter a valid phone number.
Format: (000) 000-0000.
Mental Health Status/History
What are the problem(s) for which you are seeking help?
What are your treatment goal(s)?
Have you received any counseling or psychiatric sessions before?
Yes
No
Please tell us for what reason, when, and by whom:
Have you ever been psychiatrically hospitalized?
Yes
No
Please tell us for what reason, when, and location:
Do you current have and/or have you recently had any suicidal thoughts?
Yes
No
Please explain:
Do you have any history of suicide attempts and/or self-harming behaviors?
Yes
No
Please explain:
Current Symptoms Checklist (Check once for any symptoms present)
Depressed Mood
Euphoric Moods
Unable to Enjoy Activities
Increased Irritability
Sleep Pattern Disturbance
Racing Thoughts
Loss of Interest
Increased Risk-Taking Behaviors
Poor Concentration / Forgetful
Increase Labido
Change in Appetite
Excessive Energy
Excessive Guilt
Increased Impulsivity
Fatigue
Crying Spells
Decreased Libido
Excessive Worries
Anxiety Attacks
Suspiciousness
Avoidance
Other
Family Psychiatric History (Do you have a family member who was diagnosed with any of these mental conditions?)
Bipolar disorder
Depression
Anxiety
Anger
Suicide
Schizophrenia
Post-traumatic stress
Alcohol abuse
Other substance abuse
Violence
Other
Please tell us more about it:
Are you currently taking and/or have you ever taken any psychiatric medications?
Yes
No
Please tell us the medication name, purpose, frequency, and dosage:
Are you currently experiencing any non-psychiatric medical conditions?
Yes
No
Please tell us more about it:
Are you currently taking any medications for any non-psychiatric medical conditions?
Yes
No
Please tell us the medication name, purpose, frequency, and dosage:
Do you have any allergies?
Yes
No
Please tell us more about it:
Weight (in lbs)
Height (in inches)
Are you smoking cigars or cigarettes?
Yes
No
If you have history of smoking, please explain below how often do you smoke and how much is smoked:
Are you currently drinking alcohol and/or have a history of excessive alcohol use?
Yes
No
If you have history of alcohol use, please explain below how often do you drink alcohol and how much is consumed:
Have you ever tried any of the following substances:
Methamphetamine
Cocaine
Stimulants (pills)
Heroin
LSD / Hallucinogens
Marijuana
Methadone
Pain Killer (not as prescribed)
Alcohol
Ecstasy
None
Other
If you have history of taking illicit substances, kindly elaborate below:
Do you have any legal history and/or pending legal problem?
Yes
No
Please tell us more about it:
Please upload a LEGIBLE copy of your driver license / photo ID card
*
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Patient's Signature
*
Date Signed
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Month
-
Day
Year
Date
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