ACTS - Initial Intake Form
Thank you for your interest to join the Bri.C Family. We are eager to assist you in aligning your mental health goals with your reality. Please complete our brief community intake form so we can better assist you.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Social Security Number
*
Address(If Displaced, Enter Displaced or Enter Mailing Address)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Can we text your phone number?
Can we text your phone number?
*
Yes
No
Can we leave a voicemail?
*
Yes
No
Email
*
example@example.com
Gender
*
Male
Female
Gender Identity
*
Cisgender
Transgender
Non-Binary
Undetermined
Pronouns
*
He/Him/His
She/Her
They/Them/Theirs
Race/Ethnicity
*
American Indian
Asian
African American
Hispanic
Pacific Islander
White
Other
Sexual Orientation
*
Heterosexual
Homosexual
Bisexual
Asexual
Pansexual
Undetermined
Marital Status
*
Marital Status
*
Single
Married
Seperated
Divorced
Widowed
Sexual Orientation
*
Insurance Payer
*
Insurance Type
*
Medicaid
Medicare
Private/Commercial
Tricare
None
Other
Insurance Provider
*
Aetna Better Health of Virginia
Anthem Healthkeepers Plus
Humana (Medicaid)
Medicaid
Molina Complete Care Virginia
Sentara
United Healthcare
Other
Medicaid Number
*
Who were you referred by? Name and Number. Type Self, if Self Referral
*
Who is your Emergency Contact?
*
What is the relationship to your Emergency Contact?
*
What is the address of your Emergency Contact?
*
What is the phone number of your Emergency Contact?
*
Are you a Minor?
*
Yes
No
Are you a Competent?
*
Yes
No
Are you a Incapacitated?
*
Yes
No
Do you have a Legal Guardian/Power of Attorney/Authorized Representative/Payee?
*
Yes
No
Legal Guardian/Authorized Representative/Payee Name? (Type None, If Not Applicable)
*
Legal Guardian/Authorized Representative/Payee Address? (Type None, If Not Applicable)
*
Legal Guardian/Authorized Representative/Payee Name? (Type None, If Not Applicable)
*
1. How often do you have a drink containing alcohol?
*
Never (0)
Monthly or less (1)
2-4 times a month (2)
2-3 times a week (3)
4 or more times a week (4)
2. How many drinks containing alcohol do you have on a typical day when you are drinking?
*
1 or 2 (0)
3 or 4 (1)
5 or 6 (2)
7 to 9 (3)
10 or more (4)
3. How often do you have six or more drinks on one occasion?
*
Never (0)
Monthly or less (1)
Monthly (2)
Weekly (3)
Daily or Almost Daily (4)
4. How often during the last year have you found that you were not able to stop drinking once you had started?
*
Never (0)
Monthly or less (1)
Monthly (2)
Weekly (3)
Daily or Almost Daily (4)
5. How often during the last year have you failed to do what was normally expected from you because of drinking?
*
Never (0)
Monthly or less (1)
Monthly (2)
Weekly (3)
Daily or Almost Daily (4)
6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
*
Never (0)
Monthly or less (1)
Monthly (2)
Weekly (3)
Daily or Almost Daily (4)
7. How often during the last year have you had a feeling of guilt or remorse after drinking?
*
Never (0)
Monthly or less (1)
Monthly (2)
Weekly (3)
Daily or Almost Daily (4)
8. How often during the last year have you been unable to remember what happened the night before because you had been drinking?
*
Never (0)
Monthly or less (1)
Monthly (2)
Weekly (3)
Daily or Almost Daily (4)
9. Have you or someone else been injured as a result of your drinking?
*
Never (0)
Yes, but not in the last year (2)
Yes, during the last year (4)
10. Has a relative or friend or a doctor or another health worker been concerned about your drinking or suggested you cut down?
*
Never (0)
Yes, but not in the last year (2)
Yes, during the last year (4)
What is the phone number of your Next of Kint?
*
In the past 12 months.....
*
Rows
No
Yes
1. Have you used drugs other than those required for medical reasons?
2. Do you abuse more than one drug at a time?
3. Are you always able to stop using drugs when you want to? (If never use drugs, answer “Yes.”
4. Have you had "blackouts" or "flashbacks" as a result of drug use?
5. Do you ever feel bad or guilty about your drug use? If never use drugs, choose “No.”
6. Does your spouse (or parents) ever complain about your involvement with drugs?
7. Have you neglected your family because of your use of drugs?
8. Have you engaged in illegal activities in order to obtain drugs?
9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?
10. Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc.)?
Name
First Name
Last Name
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Psychiatric Presentation
Please provide information about your current psychiatric presentation.
Please explain why you are currently seeking services
*
Are you experiencing any of the following? (Check all that apply)
*
Auditory Hallucinations (Hearing Things)
Decreased Appetite
Decreased functioning at one or more: Home, Work, School
Difficulty Focusing or Concentrating
Financial Instability
Homicidal Thoughts
Hypersomnia (Sleeping to much)
Increased Anxiety
Increased Appetite
Increased Depression
Insomnia (Cannot sleep)
Irritability/Anger
Low Interest in Activity
Low Motivation
Mood Lability
Paranoia (I.E. people are out to get you, people are listening to your conversations)
Racing Thoughts
Self-Harm
Suicidal Thoughts
Unstable Housing
Visual Hallucinations (Seeing Things)
Other
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Psychiatric History
Please provide information about your psychiatric history
Have you seen a psychiatric provider before?
*
Yes
No
Do you currently have a psychiatric provider?
*
Yes
No
Please provide your psychiatric provider's name. (Type N/A if not applicable)
*
Please list previous mental health diagnosis/conditions that have been diagnosed by a MENTAL HEALTH PROFESSIONAL.
*
Rows
Yes
No
ADHD
Autism/Aspergers
Bipolar Disorder (Manic-Depressive) Disorder)
Borderline Personality Disorder
Conduct Disorder
Generalized Anxiety Disorder
Insomnia
Major Depressive Disorder
Obsessive Compulsive Disorder
Oppositional Defiant Disorder
Panic Disorder
Psychosis
PTSD
Schizoaffective Disorder
Schizophrenia
Have you ever been admitted into a psychiatric hospital?
*
Yes
No
If you answered yes to the previous question, please explain in detail, how many times and hospital names. (N/A If Not Applicable)
*
Do you have a history of suicide attempts or self-harm?
*
Yes
No
If you answered yes to the previous question, please explain in detail, how many times and your actions. (N/A If Not Applicable)
*
Do you have any family with a history of mental health conditions? Please list.
*
Do you have any family with a history of substance abuse? Please list.
*
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Psychiatric Medications
Are you currently taking any psychiatric medications?
*
Yes
No
If so, please list below the following information: Medication Name, Dose, Frequency (Type N/A if you have never taken a psychiatric medication)
*
Psychiatric Medication Trials: Have you ever been on any of the following antidepressants, if so please check all the apply
*
Amitriptyline (Elavil)
Buproprion (Wellbutrin)
Citalopram (Celexa)
Clomipramine (Anafranil)
Duloxetine (Cymbalta)
Escitalopram (Lexapro)
Fluoxetine (Prozac)
Fluvoxamine (Luvox)
Mirtazapine (Remeron)
Nortriptyline (Pamelor)
Paroxetine (Paxil)
Sertraline (Zoloft)
Trazodone (Desyrel)
Venlafaxine (Effexor)
Vilazodone (Viibryd)
Vortioxetine (Trintellix)
N/A
Other
Psychiatric Medication Trials: Have you ever been on any of the following anti-anxiety agents, if so please check all the apply
*
Alprazolam (Xanax)
Buspirone (Buspar)
Clonazepam (Klonopin)
Clonidine
Diazepam (Valium)
Gabapentin (Neurontin)
Hydroxyzine HCL (Atarax)
Hydroxyzine Pamoate (Vistaril)
Lorazepam (Ativan)
Propranolol (Inderal)
N/A
Other
Psychiatric Medication Trials: Have you ever been on any of the following mood stabilizers, if so please check all the apply
*
Carbamazepine (Tegretol)
Gabapentin (Neurontin)
Lamotrigine (Lamictal)
Lithium
Oxcarbazepine (Trileptal)
Topiramate (Topamax)
Valproate (Depakote)
N/A
Other
Psychiatric Medication Trials: Have you ever been on any of the following anti-psychotics, if so please check all the apply
*
Aripiprazole (Abilify)
Asenapine (Saphris)
Cariprazine (Vraylar)
Chlorpromazine (Thorazine)
Clozapine (Clozaril)
Fluphenazine (Prolixin)
Haloperidol (Haldol)
Lurasidone (Latuda)
Olanzapine (Zyprexa)
Paliperidone (Invega)
Quetiapine (Seroquel)
Risperidone (Risperdal)
Ziprasidone (Geodon)
N/A
Other
Psychiatric Medication Trials: Have you ever been on any of the following treatments for ADHD, if so please check all the apply
*
Amphehtamine Salts (Adderall)
Atomoxetine (Strattera)
Clonidine (Catapres)
Guanfacine (Intuniv)
Lisdexamfetamine (Vyvanse)
Methylphenidate (Adhansia XR)
Methylphenidate (Concerta)
Methylphenidate (Ritalin)
N/A
Other
Psychiatric Medication Trials: Have you ever been on any of the following sedative/hypnotics, if so please check all the apply
*
Doxepin (Silenor)
Eszopiclone (Lunesta)
Zolpidem (Ambien)
Quetiapine (Seroquel)
Ramelteon (Rozerem)
Suvorexant (Belsomra)
Temazepam (Restoril)
Trazodone (Desyrel)
N/A
Other
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Medical History
Who is your Primary Care Provider? (N/A if you do not have one)
*
When was the last time you had a wellness exam? (N/A if you have not had one within the last year or if unknown)
*
Please list any medical conditions, diseases, and surgeries that you have or have had. (I.E. asthma, diabetes, hepatitis C, herpes, hysterectomy)
*
When was the last date you were screened for infectious diseases such as HIV, Hepatitis B, Hepatitis C, and Tuberculosis? (N/A if Not Applicable)
*
Please list any medical medication or over the counter medications you are currently taking. Please provide the following information: Medication Name, Dose, Frequency (Type N/A if you are currently not taking any medical medications)
*
Please list any allergies to food and/or drugs.
*
How tall are you?
*
How much do you weigh?
*
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Psychosocial History
Where were you born?
*
Who raised you?
*
How many siblings do you have?
*
What is your Highest Level of Education?
*
Are you currently employed? If so, where do you work and what do you do. If you are on disability please provide condition(s) you are receiving disability for.
*
Do you receive any benefits (SSD/SSI, TANF, SNAP/EBT, Child Support)?
*
Yes
No
Please provide what benefits you receive. (Type N/A if None)
*
Sexual Orientation
*
Asexual
Bisexual
Heterosexual
Homosexual
Pansexual
Do you have any children? How many?
*
Where and with whom do you live?
*
Do you hold a valid identification card or driver's license?
*
Yes
No
Are you able to effectively assess available modes of transportation?
*
Yes
No
Have you ever been arrested and/or court ordered to receive any Mental Health treatment services?
*
Yes
No
Do you have any current legal charges pending?
*
Yes
No
Are you currently on probation or parole?
*
Yes
No
If yes, please provide locality and projected end date. (Type N/A, if not applicable)
*
Have you ever been registered as a sexual offender?
*
Yes
No
If yes, please specify. (Type N/A, if not applicable)
*
Have you ever been in the military?
*
Yes
No
Do you have history of trauma/abuse?
*
Rows
Yes
No
Domestic Violence
Emotional Abuse
Neglect
Physical Abuse
Sexual Abuse
Traumatic Incident in your Life
Traumatic Loss of Individuals
Verbal Abuse
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Substance Use History
Have you ever received any substance abuse treatment?
*
Yes
No
When was the last program? How long were you in the program? What was the outcome? (N/A if Not Applicable)
*
Have you ever received any MAT services?
*
Yes
No
Have you ever received any Suboxone treatment?
*
Yes
No
Have you ever received any Methadone treatment?
*
Yes
No
Do you have a history of severe withdrawals?
*
Yes
No
Substance Use
*
Rows
Current Use
History of Use
Never Used
Alcohol
Method of Use (Alcohol)
*
Rows
Current Use
History of Use
No History of Use
Ingest
Inhale
Intravenous(IV)
Smoke
Sniff/Snort
Frequency of Use - How often do you use? (N/A if Not Applicable)
*
How much do you use? (N/A if Not Applicable)
*
What age do you begin using? (N/A if Not Applicable)
*
When did you last use? (N/A if Not Applicable)
*
Substance Use
*
Rows
Current Use
History of Use
Never Used
Amphetamines
Method of Use (Amphetamines)
*
Rows
Current Use
History of Use
No History of Use
Ingest
Inhale
Intravenous(IV)
Smoke
Sniff/Snort
Frequency of Use - How often do you use? (N/A if Not Applicable)
*
How much do you use? (N/A if Not Applicable)
*
What age do you begin using? (N/A if Not Applicable)
*
When did you last use? (N/A if Not Applicable)
*
Substance Use
*
Rows
Current Use
History of Use
Never Used
Barbituates
Method of Use (Barbituates)
*
Rows
Current Use
History of Use
No History of Use
Ingest
Inhale
Intravenous(IV)
Smoke
Sniff/Snort
Frequency of Use - How often do you use? (N/A if Not Applicable)
*
How much do you use? (N/A if Not Applicable)
*
What age do you begin using? (N/A if Not Applicable)
*
When did you last use? (N/A if Not Applicable)
*
Substance Use
*
Rows
Current Use
History of Use
Never Used
Benzodiazepine
Method of Use (Benzodiazepines)
*
Rows
Current Use
History of Use
No History of Use
Ingest
Inhale
Intravenous(IV)
Smoke
Sniff/Snort
Frequency of Use - How often do you use? (N/A if Not Applicable)
*
How much do you use? (N/A if Not Applicable)
*
What age do you begin using? (N/A if Not Applicable)
*
When did you last use? (N/A if Not Applicable)
*
Substance Use
*
Rows
Current Use
History of Use
Never Used
Caffeine
Method of Use (Caffeine)
*
Rows
Current Use
History of Use
No History of Use
Ingest
Inhale
Intravenous(IV)
Smoke
Sniff/Snort
Frequency of Use - How often do you use? (N/A if Not Applicable)
*
How much do you use? (N/A if Not Applicable)
*
What age do you begin using? (N/A if Not Applicable)
*
When did you last use? (N/A if Not Applicable)
*
Substance Use
*
Rows
Current Use
History of Use
Never Used
Cocaine
Method of Use (Cocaine)
*
Rows
Current Use
History of Use
No History of Use
Ingest
Inhale
Intravenous(IV)
Smoke
Sniff/Snort
Frequency of Use - How often do you use? (N/A if Not Applicable)
*
How much do you use? (N/A if Not Applicable)
*
What age do you begin using? (N/A if Not Applicable)
*
When did you last use? (N/A if Not Applicable)
*
Substance Use
*
Rows
Current Use
History of Use
Never Used
Hallucinogens
Method of Use (Hallucinogens)
*
Rows
Current Use
History of Use
No History of Use
Ingest
Inhale
Intravenous(IV)
Smoke
Sniff/Snort
Frequency of Use - How often do you use? (N/A if Not Applicable)
*
How much do you use? (N/A if Not Applicable)
*
What age do you begin using? (N/A if Not Applicable)
*
When did you last use? (N/A if Not Applicable)
*
Substance Use
*
Rows
Current Use
History of Use
Never Used
Inhalants
Method of Use (Inhalants)
*
Rows
Current Use
History of Use
No History of Use
Ingest
Inhale
Intravenous(IV)
Smoke
Sniff/Snort
Frequency of Use - How often do you use? (N/A if Not Applicable)
*
How much do you use? (N/A if Not Applicable)
*
What age do you begin using? (N/A if Not Applicable)
*
When did you last use? (N/A if Not Applicable)
*
Substance Use
*
Rows
Current Use
History of Use
Never Used
Marijuana
Method of Use (Marijuana)
*
Rows
Current Use
History of Use
No History of Use
Ingest
Inhale
Intravenous(IV)
Smoke
Sniff/Snort
Frequency of Use - How often do you use? (N/A if Not Applicable)
*
How much do you use? (N/A if Not Applicable)
*
What age do you begin using? (N/A if Not Applicable)
*
When did you last use? (N/A if Not Applicable)
*
Substance Use
*
Rows
Current Use
History of Use
Never Used
Nicotene
Method of Use (Nicotene)
*
Rows
Current Use
History of Use
No History of Use
Ingest
Inhale
Intravenous(IV)
Smoke
Sniff/Snort
Frequency of Use - How often do you use? (N/A if Not Applicable)
*
How much do you use? (N/A if Not Applicable)
*
What age do you begin using? (N/A if Not Applicable)
*
When did you last use? (N/A if Not Applicable)
*
Substance Use
*
Rows
Current Use
History of Use
Never Used
Opiates
Method of Use (Opiates)
*
Rows
Current Use
History of Use
No History of Use
Ingest
Inhale
Intravenous(IV)
Smoke
Sniff/Snort
Frequency of Use - How often do you use? (N/A if Not Applicable)
*
How much do you use? (N/A if Not Applicable)
*
What age do you begin using? (N/A if Not Applicable)
*
When did you last use? (N/A if Not Applicable)
*
Substance Use
*
Rows
Current Use
History of Use
Never Used
PCP
Method of Use (PCP)
*
Rows
Current Use
History of Use
No History of Use
Ingest
Inhale
Intravenous(IV)
Smoke
Sniff/Snort
Frequency of Use - How often do you use? (N/A if Not Applicable)
*
How much do you use? (N/A if Not Applicable)
*
What age do you begin using? (N/A if Not Applicable)
*
When did you last use? (N/A if Not Applicable)
*
Substance Use
*
Rows
Current Use
History of Use
Never Used
Other
Method of Use (Other
*
Rows
Current Use
History of Use
No History of Use
Ingest
Inhale
Intravenous(IV)
Smoke
Sniff/Snort
Frequency of Use - How often do you use? (N/A if Not Applicable)
*
How much do you use? (N/A if Not Applicable)
*
What age do you begin using? (N/A if Not Applicable)
*
When did you last use? (N/A if Not Applicable)
*
Other Substances. Please Explain (Type N/A if None)
*
What is your longest period of sobriety?
*
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Current Psychiatric Assessments
In the past 2 weeks, how often have they been bothered by the following:
*
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 or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself — or that you are 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 so fidgety or restless that you have been moving a lot more than usual
Thoughts that you would be better off dead, or thoughts of hurting yourself in some way
If you had to rate your mood (how happy or sad you are) in the past week, what would you rate it?
*
Worst
0
1
2
3
4
5
6
7
8
9
Best
10
0 is Worst, 10 is Best
In the past 2 weeks, how often have they been bothered by the following:
*
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's hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen
If you had to rate your anxiety in the past week, what would you rate it?
*
None
0
1
2
3
4
5
6
7
8
9
Worst
10
0 is None, 10 is Worst
Has there ever been a period of time when you were not your usual self and...
*
Rows
Yes
No
...you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?
...you were so irritable that you shouted at people or started fights or arguments?
...you felt much more self-confident than usual?3
...you got much less sleep than usual and found you didn’t really miss it?
...you were much more talkative or spoke much faster than usual?
...thoughts raced through your head or you couldn’t slow your mind down?
...you were so easily distracted by things around you that you had trouble concentrating or staying on track?
...you had much more energy than usual?
...you were much more active or did many more things than usual?
...you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?
...you were much more interested in sex than usual?
...you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?
...spending money got you or your family into trouble?
If you checked YES to more than one of the above, have several of these ever happened during the same period of time?
Problem
*
Rows
No Problem
Minor Problem
Moderate Problem
Serious Problem
How much of a problem did any of these cause you – like being unable to work; having family, money or legal troubles; getting into arguments or fights?
History of Manic-Depressive Illness or Bipolar
Rows
Yes
No
Have any of your blood relatives (i.e. children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder?
Has a health professional ever told you that you have manic-depressive illness or bipolar disorder?
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Pharmacy
What pharmacy would you like to use? Please provide name and address.
*
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