ADULT In-take Form
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance Information
Kindly fill in your insurance information on this form and upload a photo of the back and front of your insurance card below.
Insurance Company Name
*
"Please upload a photo of the front side of your insurance card"
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of
"Please upload a photo of the back side of your insurance card"
Browse Files
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Choose a file
Cancel
of
*
Member ID#
Group #
*
Deductible Information
CoPay
Secondary Insurance/Company Name
*
*
Member ID#
Group #
*
Deductible Information
CoPay
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Other
Primary Care Physician
First Name
Last Name
Current Therapist / Counselor
First Name
Last Name
Therapist's Phone Number
Format: (000) 000-0000.
Please list the problem(s) which you are seeking help?
Current Symptoms
Depressed mood
Racing thoughts
Excessive worry
Unable to enjoy activities
Impulsivity
Anxiety attacks
Sleep pattern disturbance
Increase risky behavior
Avoidance
Loss of interest
Increased libido
Hallucinations
Concentration/forgetfulness
Decrease need for sleep
Suspiciousness
Change in appetite
Excessive energy
Excessive guilt
Increased irritability
Fatigue
Crying spells
Decreased libido
Other
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?
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?
Weak
1
2
3
4
5
6
7
8
9
Strong
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?
Medical History
Do you have any allergies? (If yes, please list them)
Current Weight
Current Height
List all current prescription medications and how often you take them
Current medical problems
Past medical problems, nonpsychiatric hospitalization, or surgeries
For women only:
Psychiatric History:
Outpatient treatment
Yes
No
If yes, Please describe when, by whom, and nature of treatment
Psychiatric Hospitalization
Yes
No
If yes, Please describe when, by whom, and nature of treatment
Past Psychiatric Medications
If you have ever taken any of the following medications, please indicate the dates and daily dosage.
Rows
Have you ever taken it?
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)
Lithium
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)
Buspar (buspirone)
Other medications?
Family Psychiatric History
Has anyone in your family been diagnosed with or treated for:
Bipolar disorder
Depression
Anxiety
Anger
Suicide
Schizophrenia
Post-traumatic stress
Alcoholabuse
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?
Yes
No
How much time each day do you exercise?
Check if you have ever tried the following
Methamphetamine
Cocaine
Stimulants (pills)
Heroin
LSD or Hallucinogens
Marijuana
Pain killers (not as prescribed)
Methadone
Tranquilizer/sleeping pills
Alcohol
Ecstasy
Other
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
Where did you grow up?
List your siblings and their ages:
*
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
Please list ages and gender:
*
Have you ever been arrested?
Yes
No
Additional information
Emergency Contact
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Date
-
Month
-
Day
Year
Date
Signature
Guardian Signature (if under age 18)
Dr. Joseph A. Schembri Jr. ~ 5 North Meadows Road ~ Medfield, MA 02052 ~ Phone: 1-508-246-6493 ~ e-mail: bhn@behavioralhealthnetwork.org or bschembri@behavioralhealthnetwork.org
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