New Patient Intake Form

Branch Mental Health PLLC

651-333-3677 (phone) | www.branchmentalhealth.com
New Patient Intake Form - Adult

Please let us know if you need assistance completing this form or would like this form in another language.
Demographic Information

Tell us a little about yourself!
Name

First NameMiddle NameLast Name
Preferred name if different than above:
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

How would you like to be contacted:

Rows	Yes	No	Okay to leave detailed message?
Voicemail
E-mail
Text

Emergency Contact Information

Rows	First Name	Last Name	Relationship	Phone number
Emergency Contact 1
Emergency Contact 2

How were you referred to us?
Reason for visit:

MEDICAL HISTORY
Please check if you have had any of the following:
Please list any other major medical history (e.g.: diabetes, asthma):
Please list any surgeries you have had:

Please list all CURRENT medications or supplements you take:

Rows	Medication Name (example: citalopram)	Dose (example: 10 mg)	How often? (example: daily)	Time of day taken (example: 8 pm)	Reason (example: anxiety)	Side effects (example: fatigue)
1
2
3
4
5
6
7

Please list any PAST medications or supplements you have tried for MENTAL HEALTH or SLEEP (complete the best you can):

Rows	Medication Name (example: citalopram)	Dose (example: 10 mg)	How often? (example: daily)	Time of day taken (example: 8 pm)	Reason (example: anxiety)	Side effects (example: fatigue)
1
2
3
4
5
6
7

Please list any ALLERGIES to medications along with the reaction you have (example: sulfa - rash):
Reproductive History

Please complete where it applies to you.
Any possibility of pregnancy or are you currently trying to conceive?

Pregnancy History

Rows	Total #	Complications/Concerns
Pregnancies
Live births
Miscarriages
C-sections
Vaginal deliveries
Elective abortions

Rows	Mother	Father	Sibling 1	Sibling 2	Sibling 3	Other
Depression
Anxiety disorder
Panic disorder
Bipolar disorder
Schizophrenia
Addiction/substance use disorder
OCD
ADHD
PTSD
Suicide attempts
Suicide completion
Eating disorder

Rows	Current use	Used within past year	Last use more than 1 year ago	Never used
Alcohol
Nicotine or tobacco
Cannabis or marijuana
Methamphetamine/other stimulants or prescription stimulant misuse
Heroin, fentanyl, or other nonprescription opioids
Prescription opioid medication misuse
Benzodiazepines/other sedatives/hypnotics/sleeping medication misuse
Cocaine/crack
Other

Rows	Not at all (0)	Several days (1)	More than half the days (2)	Nearly every day (3)
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling asleep, staying asleep, or sleeping too much
Feeling tired of having little energy
Poor appetite or overeating
Feeling bad about yourself - or that you're a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety and restless that you have been moving around a lot more than usual
Thoughts that you would be better off dead or of hurting yourself in some way

Rows	Not at all (0)	Several days (1)	More than half the days (2)	Nearly every day (3)
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritated
Feeling afraid as if something awful might happen

Rows	Yes	No
Do you make yourself vomit because you feel uncomfortably full?
Do you worry that you have lost control over how much you eat?
Have you recently lost more than 15 pounds in a 3-month period?
Do you believe you are fat when others say you are too thin?
Would you say that food dominates your life?

Branch Mental Health PLLC

New Patient Intake Form - Adult

Demographic Information

MEDICAL HISTORY

Reproductive History

Psychiatric History

FAMILY HISTORY

SOCIAL HISTORY

Screening Forms

PHQ-9

GAD-7

SCOFF

CAGE-AID

ACE (Adverse Childhood Events) Questionnaire

Congrats! You made it! : ) Now just hit "submit" below.

Rows	Yes	No
Have you ever felt the need to cut down on your drinking or drug use?
Have people annoyed you by criticizing your drinking or drug use?
Have you ever felt guilty about drinking or drug use?
Have you ever felt you needed a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)?

Rows	No (0)	Yes (1)
Did a parent or other adult in the household often or very often... Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt?
Did a parent or other adult in the household often or very often... Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured?
Did an adult or person at least five years older than you ever... Touch or fondle you or have you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you?
Did you often or very often feel that... No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other?
Did you often or very often feel that... You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
Were your parents ever separated or divorced?
Was your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit at least a few minutes or threatened with a gun or knife?
Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
Was a household member depressed or mentally ill, or did a household member attempt suicide?
Did a household member go to prison?