Mental Health Intake Form
All information on this form is strictly confidential
Current Symptoms Checklist
Please check all appropriate columns
Yes
No
N/A
Aggression
Agitation
Anger
Anxiety
Appetite Change
Change in Libido
Compulsions
Crying/Tearful
Cyber Addiction
Delusions
Depression
Disorientation
Difficulty Getting Out of Bed
Difficulty Making Decisions
Distractibility
Eating Disorder
Elevated Mood
Emotional Trauma Perpetrator
Emotional Trauma Victim
Excessive Energy
Fatigue
Grief
Guilt
Gambling
Hallucinations
Hearing Voices
Heart Palpitations
Hopelessness
Hyperactivity
Impulsivity
Yes
No
N/A
Irritability
Judgment Errors
Loneliness
Loss of Interest in Activities
Memory Impairment
Mood Swings
Obsessions
Oppositional Behavior
Panic Attacks
Paranoia
Phobias/Fears
Physical Trauma Perpetrator
Physical Trauma Victim
Poor Concentration
Poor Grooming
Racing Thoughts
Recurring Thoughts
Self-Mutilation
Sexual Addiction
Sexual Difficulties
Sexual Trauma Perpetrator
Sexual Trauma Victim
Sleep Problems
Speech Problems
Social Isolation
Substance Abuse
Suicidal Thoughts
Worried
Worthlessness
Other
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Socio-Economic History
Living Situation:
Yes
No
N/A
Social Support System:
Yes
No
N/A
Financial Situation:
Yes
No
N/A
Employment:
Yes
No
N/A
Legal History:
Yes
No
N/A
Military History:
Yes
No
N/A
Sexual History:
Yes
No
N/A
Relationship History and Current Family:
Yes
No
N/A
Cultural/Spiritual/Recreational History: Cultural Identity (Ethnicity, Religion) Describe any cultural issues that contribute to current problem(s)
Yes
No
Currently active in community/recreational activities?
Formerly active in community/recreational activities?
Currently engage in hobbies?
Currently participate in spiritual activities?
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Personal and Family Medical History
Have you or a family member ever had any of the following?
You
Family
N/A
Alzheimer's/Dementia
Anemia
Arthritis
Asthma
Behavioral Problems
Birth Defects
Cancer
Chronic Fatigue
Chronic Pain
Diabetes
Ear/Nose/Throat Problems
Eating Disorder
Emotional Problems
Endocrine/Hormone Problems
Epilepsy or Seizures
Eye Problems
Fibromyalgia
Gastrointestinal Problems
Genital/Gynecological Problems
Head Injury
Heart Disease
High Blood Pressure
High Cholesterol
HIV Positive or AIDS
Kidney Problems
Liver Problems/Hepatitis
Lung Disease
Mental Retardation
Migraine or Cluster Headaches
Neurological Problems
Skin Disease
Sleep Apnea
Stroke
Thyroid Disease
Tuberculosis
Urological Problems
Viral Illness/Herpes
Other
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Family History
Has anyone in your family ever been treated for any of the following?
Father
Mother
Brother
Sister
Children
Paternal Grandparent
Maternal Grandparent
Paternal Aunt
Maternal Aunt
Paternal Uncle
Maternal Uncle
ADHD
Alcohol Problems
Anxiety
Bipolar Disorder/Manic Depression
Depression
Drug Problems
Panic Attacks
Post Traumatic Stress
Psychiatric Hospitalization
Schizophrenia
Suicide Attempts
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Somewhat Satisfied
Satisfied
Any thoughts?
Service Quality
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Responsiveness
Friendliness
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