ADULT Mental Health Intake Form

ADULT BEHAVIORAL HEALTH INTAKE FORM
Patient Information
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Gender at Birth*
Gender Identity*
Race*
Ethnicity*
Nationality (ketamine consults only)

BritishScottishRussianIrishGreekPolishChineseGerman
Contact Information
Address*

Street Address

Unit / Apt / Suite

CityState / Province

Postal / Zip Code
Contact Number*
Please enter a valid phone number.
Email*
example@example.com
Preferred Method of Communication*
Emergency Contact
Print Name

First NameLast Name
Contact Number
Please enter a valid phone number.
Relationship to Patient
Reason(s) for Consultation

Select All That Apply

Please select all the reasons for your consultation that apply to you from the list below. If you do not see your specific reason, select "Other" and specify under "Comments."

	Reason for Consultation	Comments
ADHD Evaluation & Testing (T.O.V.A)
ADHD Management
Alcohol Use Disorder
Anxiety
Autism Spectrum Disorder
Binge Eating Disorder
Bio-identical Hormone Replacement
Bipolar Disorder
Depression
I haven't felt like myself lately, seeking professional opinion
Initial Psychiatric Evaluation
IV Hydration Therapy (Self-Pay Only)
Ketamine Assisted Psychotherapy
Ketamine Therapy (Self-Pay Only)
Medical Weight Loss - Semaglutide
Obsessive-Compulsive Disorder (OCD)
Outpatient Medication Management
Personality Disorder
Pharmacogenetic (PGx) Testing
Premenstrual Dysphoric Disorder (PMDD)
Psychiatric Evaluation Requested by Authority
PTSD/Trauma
RMV Evaluation (Self-Pay Only)
SARP Evaluation (Substance Addiction Recovery Program for MA Nurses)
Schizophrenia/Hallucinations
Sleep Pattern Disturbance
Suboxone / Sublocade
Self-harm / Cutting
Suicidal Thoughts
Substance Abuse Treatment
Vivitrol
Wellness Injections (Self-Pay Only)
Other (specify under "Comments")

Current Symptom(s)

Please select all the current symptoms that apply to you from the list below. For each symptom selected, please provide the following details:
- Duration: How long you have been experiencing the symptom
- Frequency: How often you experience the symptom
- Consequences: The effects or impact of the symptom on your daily life
- Comments: Any additional details or context you wish to provide
**If none of these symptoms apply, please select 'Not Applicable' and proceed to the next section.

Symptom(s) Checklist (select all that apply)

	Current Symptom	Duration	Frequency	Consequences	Comments
Not Applicable
Abnormal Movements
Agitation
Alcohol Dependence
Anger & Irritability
Anhedonia (Inability to Feel Pleasure)
Anxiety Attacks
Avoidance
Bereavement / Grief
Change in Appetite
Cognitive Decline
Concentration / Forgetfulness
Crying Spells
Decreased Libido
Decreased Need for Sleep
Delusions
Depressed Mood
Detachment from Reality
Disorientation
Dissociation
Excessive Energy
Excessive Guilt
Excessive Worry
Fatigue
Feelings of Worthlessness
Flashbacks / Hypervigilance
Frequent Nightmares
Grandiosity
Hallucinations
Hopelessness
Hyperactivity
Hypersomnia
Hypervigilance
Impulsivity
Increased Irritability
Increased Libido
Increased Risky Behavior
Insomnia
Irrational Fears
Loss of Interest
Low Self-Esteem
Mania
Memory Impairment
Mood Swings
Obsessions / Compulsions
Panic Attacks
Paranoia
Physical Complaints with No Medical Cause (e.g., Unexplained Physical Symptoms)
Poor Hygiene
Psychosis
Racing Heart
Racing Thoughts
Regressive Behavior (e.g., behaviors not typical for age)
Restlessness
Rumination (Repetitive Negative Thoughts)
Self-Harm / Cutting
Social Withdrawal
Somatic Complaints (e.g., Unexplained Physical Symptoms)
Substance Abuse
Suicide Ideations
Suspiciousness
Tearfulness
Thought Blocking
Truancy/Absenteeism (work or school)
Unable to Enjoy Activities
Uncontrolled Anger
Unwanted Thoughts
Other (specify under "Comments")

Goals of Treatment*
Medical History
Current Height*
Current Weight*
Do you have a Primary Care Provider?*

Yes, please provide details in the next sectionNo
Primary Care Provider
Specialists - Please provide the name and phone number of any specialists you are currently seeing
Allergies
Do you have any known drug, environmental, or food allergies?*

Yes, please specify belowNo Known Allergies
List all known drug, environmental, or food allergies, your reaction, severity and when it occurred
Preferred Pharmacy*
Non-Psychiatric Medications

If you are not currently taking any prescribed or over-the-counter medications, vitamins or supplements, proceed to the next section.
Please provide a list of all current non-psychiatric and OTC medications, dose & frequency including birth-control, supplements and vitamins.
Past Medical History

Please check the box if you have a history of any of the following medical conditions, and indicate whether the condition is active or resolved. Where applicable, provide details and your treatment course under 'Comments.' If none of these conditions apply, please select 'None of the Above' and proceed to the next section.

	Confirmed Diagnosis	Active Problem	Resolved	Comments
Aneurysmal Vascular Disease (including thoracic and abdominal aorta, intracranial and peripheral arterial vessels)
Arteriovenous Malformation
Atrial Fibrillation
Autoimmune Disease ( (specify under 'Comments')
Cancer (specify under 'Comments')
Chronic Kidney Disease
Chronic Lung Disease (e.g., COPD, Asthma)
Chronic Pain Conditions (e.g., Fibromyalgia)
Diabetes
Female Hormone Disorders (e.g., PCOS, PMS/PMDD, Endometriosis, Menopause)
Gastrointestinal Disorders (e.g., IBS, Crohn’s Disease, Ulcerative Colitis)
Heart Disease (specify under 'Comments')
High Cholesterol
Hypertension (High Blood Pressure)
Liver Dysfunction (specify under 'Comments')
Low Testosterone
Neurological Disorders (specify under 'Comments')
Porphyria
Sleep Disorder (specify under 'Comments')
Thyroid Disorder (specify under 'Comments')
Traumatic Brain Injury
Other (specify under 'Comments')
None of the above

Other Current Medical Problems – If you do not have any other current medical conditions to report, proceed to the next section
Please provide the diagnosis, date or year diagnosed, treatment course and treating provider /practice name
List all Non-Psychiatric Hospitalizations, Reason for Treatment and Treatment Dates
List all Surgeries and dates
Please list surgeries from most recent to oldest. Provide year, procedure, hospital/facility and name of surgeon
Have you ever had a EKG?*

YesNo
If yes, when?
Was the EKG normal?

YesNoUnknown
Request for EKG Results

Skip this section if this does not apply to you
- In order to continue your treatment with stimulant medication, or if you are taking two or more antipsychotic medications, it is essential that we have a recent Electrocardiogram (EKG) result on file. This is to ensure your overall cardiac health and safety while using these medications.
- If you have had an EKG within the last year, please upload a copy of the results below. If you do not have a recent EKG (less than 1 year old), we will need to schedule one.
- This is a standard precaution to monitor any potential cardiac effects that can be associated with these types of medications. Your safety and health are our primary concern, and we appreciate your cooperation in providing this necessary information.
- Please do not hesitate to contact our office if you have any questions or need assistance in scheduling your EKG.
Upload EKG Results

Please upload a copy of your EKG results if you are requesting continuation of stimulant medication or take 2 or more antipsychotic medications. All data shared through this platform is HIPAA compliant and secure
Cancelof
For women only:
Exercise Level
Do you exercise regularly?*

YesNo
How much time each day do you exercise?
How many days a week do you exercise?
Do you have any concerns about your physical health that you would like to discuss with us?*

YesNo
Date and place of your last physical exam?
Birth History: When your mother was pregnant with you, were there any complications during the pregnancy or birth?*

Yes, please specify belowNo
Birth complications
SUICIDE RISK ASSESSMENT

In the past month, have you?

	Yes	No
1) Wished you were dead or wished you would go to sleep and never wake up
2) Have you actually had any thoughts of killing yourself?
If YES to Question 2, answer Questions 3, 4, 5 and 6. If NO to Question 2, go directly to Question 6
3) Have you been thinking about how you might do this?
4) Have you had these thoughts and had some intention of acting on them? As opposed to “I have the thoughts but I definitely will not do anything about them.”
5) Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?
6) Have you ever done anything, started to do anything, or prepared to do anything to end your life?
7) If Yes to Question 6, was this within the past 3 months?*
8) Do you have access to firearms?

Psychiatric History
Outpatient treatment*

YesNo
Are you currently under the care of a psychiatric provider?*

YesNo
Name of Current Psychiatric Provider

First NameLast Name
Current Psychiatric Provider Phone No.
Please enter a valid phone number.
Dates of Psychiatric Treatment
e.g. 3/2022 to 6/2024
Past Psychiatric Providers and Dates of Treatment
Do you currently have a therapist or counselor?*

YesNo
Name of Current Therapist or Counselor

First NameLast Name
Current Therapist or Counselor Phone No.
Please enter a valid phone number.
Dates of Treatment
Past Therapist or Counselors and Dates of Treatment

Please check all that apply if you have ever been diagnosed with any of the following psychiatric conditions. If you have never been diagnosed with any of these conditions, please select 'None - this is my first psychiatric contact' and proceed to the next section.

	Confirmed Diagnosis	Diagnosing Physician	Prescribed Treatments	Comments
None - this is my first psychiatric contact
ADHD
Alcohol Use Disorder
Anxiety
Autism
Bipolar Disorder
Borderline Personality Disorder
Depression
Dissociative Disorders
Eating Disorder
Gender Dysphoria
Insomnia Disorder
Learning Disorder
Obsessive Compulsive Disorder (OCD)
Opioid Use Disorder
Personality Disorders
Phobias (Specific or Social)
Postpartum Depression
PTSD
Schizoaffective Disorder
Schizophrenia
Seasonal Affective Disorder (SAD)
Somatoform Disorders
Substance Abuse
Substance Use Disorder
Suicide Attempt
Traumatic Brain Injury
Other (specify in "Comments"

Have you ever been hospitalized for psychiatric reasons?*

YesNo
If yes, please provide the following details for each hospitalization:
Please list the name of the facility, type of treatment received, dates of service or length of treatment
Personal history of suicide attempt, suicide ideation and/or self-harm*

YesNo
History of Ketamine/Spravato treatment?*

YesNo
History of ECT, TMS treatment?*

YesNo
Trauma/Abuse History

While this information helps us provide the best possible care, it is completely voluntary, and you may choose not to answer if you do not feel comfortable sharing at this time. All information will be kept strictly confidential.
Please select all the categories that apply to your personal history of trauma or abuse.

No history of trauma or abusePhysical trauma or abuseSexual trauma or abuseNeglectParental trauma or abuseTrauma or abuse experienced in adulthoodTrauma or abuse experienced in childhoodTrauma related to military combatIntimate partner violenceEmotional or psychological abuseBullying or harassmentWitness to domestic violenceWitness to a traumatic event (e.g., accident, disaster)Financial abuse or exploitationCultural or racial traumaMedical trauma (e.g., traumatic hospital experience, severe illness)Religious or spiritual abuseHistorical or generational traumaTrauma related to natural disastersOnline or cyber abuseWorkplace traumaCommunity violenceI am unsure how to describe my experienceI prefer not to disclose this information at this timeI prefer to discuss this when we meetOther
If yes, please describe when, where and by whom.
Are you currently taking any psychiatric medications?*

Yes, please provide details belowNo
Current Psychiatric Medications

If you are not currently taking any psychiatric medication, skip the next two sections. However, if you are, please provide a list of all current psychiatric medications you are taking.
For each medication, please include the following details:
Have you found any psychiatric medications to be effective, either in the past or currently?

YesNo
Past Psychiatric Medications

If you have never taken any of these medications, please select 'None of the Above' and proceed to the next section.

Check YES if you have ever taken any of the following medications. Please indicate the dose, frequency, treatment dates, efficacy, reason for stopping and side effects (if any).

	Yes	Dosage	Frequency	Dates	Was the medication effective?	Reason Stopped	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)
Latuda (lurasidone)
Vraylar (cariprazine)
Clozaril (clozapine)
Haldol (haloperidol)
Prolixin (fluphenazine)
Risperdal (risperidone)
Ambien (zolpidem)
Lunesta (eszopiclone)
Restoril (temazepam)
Sonata (zaleplon)
Rozerem (ramelteon)
Desyrel (trazodone)
Adderall (amphetamine)
Vyvanse (lisdexamfetamine)
Concerta (methylphenidate)
Ritalin (methylphenidate)
Focalin (dexmethylphenidate)
Strattera (atomoxetine)
Xanax (alprazolam)
Ativan (lorazepam)
Klonopin (clonazepam)
Valium (diazepam)
Tranxene (clorazepate)
Buspar (buspirone)
Spravato (esketamine)
Auvelity
Ketamine (IV, IM, troches)
Other Medication

Substance Use History
Do you have a history of substance use?*

Yes, please specify belowNo
Please check YES if you have ever tried any of the substances listed below. For each substance selected, provide the following details:
- First Use – The age when you first used the substance.
- Frequency of Use – How often you used the substance (e.g., occasionally, weekly, daily).
- Amount Used – The typical quantity or dose used (e.g., five drinks/day, 1 gram/day).
- Route of Use – The method by which you used the substance (e.g., orally, intravenously, inhaled, smoked, snorted).
- Last Use – When you last used the substance (e.g., last week, month, year).
- Consequences of Use – Any significant outcomes or effects resulting from your use (e.g., health issues, legal troubles, relationship impacts).

Tobacco Use*
Have you ever smoked cigarettes?*

YesNo
If yes, please provide the following details:
How many caffeinated beverages do you drink a day?
History of substance or alcohol abuse treatment?*

YesNo
If yes, please provide the following details for each treatment episode:
Please list the name of the facility, type of treatment received, dates of service or length of treatment
ADHD Evaluation & Treatment History

Proceed to the next section if you are not seeking an ADHD evaluation
Do you have a confirmed ADHD/ADD diagnosis?

YesNo
Age at the time of ADHD/ADD diagnosis
Diagnosing Clinician
Have you ever had formal neuropsychological testing?

YesNo
Date of testing

MonthDayYear
Use 1 as the day if exact date is unknown - e.g. 04/01/2023
Do you have a copy of the evaluation? If yes, please provide a copy before your initial evaluation. If unavailable, request it to be sent to our clinic via fax at (617) 250-8262

YesNo
Upload ADHD Evaluation

Please upload a copy of your ADHD evaluation and any other supporting documentation prior to your scheduled consultation. You can also fax it to 617-250-8262
Cancelof
Have you ever been prescribed ADHD medication?

YesNo
If yes, list medication(s), dose, frequency, treatment dates, effectiveness, reason for stopping, side effects (if any), and prescriber’s name.
ONLY list ADHD medications in this section.
Family Background and Childhood History:

Please note: The information gathered from these questions is confidential and used solely for the purpose of better understanding your background and informing your treatment. If any of these questions make you uncomfortable, you have the right to refuse to answer.
Place of Birth*
Where did you grow up?*
Were you adopted?*

YesNo
Do you have any siblings?*

YesNoHalf-siblings
Birth Order*
Example: Only Child, Eldest of 3, youngest of 5
List your siblings name, age and gender from oldest to youngest
Did your parents divorce?*

YesNo
If yes, at what age were you when they divorced?
How would you describe your overall childhood experience? *
Do you have any children? (adopted or biological)*

YesNoExpecting/PregnantAdoptedOther
List each child from oldest to youngest*
Social History
Highest Level of Education Completed?*
School /University
Degree / Certification Obtained
Occupation
Employment Status*

Full-timePart-timeStudentUnemployedDisabledRetired
Relationship Status*
Length of Current Relationship
Current living situation*
Please select the option that best describes your current living situation
Primary Residence*
Family Medical History
Are you biological parents alive?*

Both parents are deceased, please specify.Both parents are alive, please specify their current age and health status.My mother is alive but my father is deceased, please specify.My father is alive but my mother is deceased, please specifyI am not in contact with my biological parents (please specify the last known health status and age).I am adopted and do not know my family history.
Please specify each biological parents last known health status and age. If deceased, please provide age at the time of death, cause of death and when it occurred, and any known medical conditions (e.g., cancer, heart disease, mental health disorders, etc.)

Please check all that apply for both 1st and 2nd degree relatives with the following medical conditions. Indicate your relationship with the family member under "Relationship" and provide details under "Comments" where applicable. If none of these apply, please select "None of the Above" and move on to the next section.

	+ Family History	Relationship?	Comments
Autoimmune Disorders (specify)
Asthma/Respiratory Problems
Cancer (specify type)
Dementia
Diabetes
Heart Disease
Hypertension
High Cholesterol
Liver Dysfunction
Sudden Cardiac Death < 40 years old
Neurological Disorders (specify)
Obesity
Seizure Disorder
Stroke / intracerebral hemorrhage
Thyroid Disease (specify)
Other disorder (specify)
None of the Above

Family Psychiatric History

This information is important as it can help us understand your potential health risks.

Please check all that apply for both 1st and 2nd degree relatives with the following psychiatric conditions. Indicate your relationship with the family member under "Relationship" and provide details under "Comments" where applicable. If none of these apply, please select "None of the Above" and move on to the next section

	+Family History	Relationship?	Comments
ADHD
Alcohol Use Order
Anxiety
Autism
Bipolar Disorder
Borderline Personality Disorder
Completed Suicide
Depression
Learning Disorder (specify)
Obsessive Compulsive Disorder
PTSD
Schizophrenia
Substance Abuse (specify)
Suicide Ideation/Self-harm
None of the Above

Has anyone in your family (living or deceased) been diagnosed with or treated for any of the following psychiatric conditions? Please check all that apply for both 1st and 2nd degree relatives.*

ADHDAlcohol Use OrderAnxietyAutismBipolar DisorderBorderline Personality DisorderDepressionLearning DisorderPTSDSchizophreniaSubstance Use DisorderSuicide Ideation/Self-harmI'm not in contact with my familyI'm adopted and do not know my family historyNo Known Family Psychiatric HistoryOther
If yes, who was treated, what condition, what medications did they take, and how effective was the treatment?
Family History of Completed Suicide*

YesNo
Please provide this information for each relevant family member: 1) Relationship to Family Member 2) Age at Time of Suicide 3) Means of Suicide
Treatment Authorization

By providing my electronic signature below, I confirm that:
- I hereby authorize Aspire Medical Group and its practitioners to provide mental health services, including evaluations and/or treatment for myself or the individual named above.
- I certify that I have read this form in its entirety and fully understand its contents. I have been given the opportunity to ask questions, and all of my questions have been answered to my satisfaction.
- I have informed Aspire Medical Group of my medical history, including known allergies, current medications, supplements, and any past adverse reactions.
- I accept the risks, conditions, and terms of the proposed treatment.
- I acknowledge that my provider reserves the right to discontinue or adjust the treatment plan as necessary. Failure to comply with the terms of this agreement may result in discontinuation of treamtent.
- No guarantees have been made regarding the outcome of this treatment.
- I certify that I have read this form, fully understand its contents, and have had all my questions answered.
- I acknowledge that I am responsible for the payment of any services I receive.
- To the best of my ability, I have provided complete and truthful information.
- I have the right to be informed of the procedure, alternative options, and the associated risks and benefits.
- I acknowledge that no guarantees have been made regarding the outcome of this treatment.
- By signing this form, I voluntarily consent to treatment, agree to the use of electronic records and signatures, and confirm that I have the legal authority to be bound by this agreement. I voluntarily accept the risks, conditions, and terms outlined in this document.
Electronic Signatures
By providing my electronic signature below, I agree to the terms and conditions outlined in this agreement. I agree to the use of electronic records and signatures. I acknowledge that I have read the related consumer disclosure.

The parties acknowledge and agree that this consent form may be executed by electronic signature, which shall be considered as an original signature for all purposes and shall have the same force and effect as an original signature. Without limitation, “electronic signature” shall include faxed versions of an original signature or electronically scanned and transmitted versions (e.g., via PDF) of an original signature.
Patient Signature*

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Print Name *

First NameLast Name
Effective Date*

MonthDayYear
Date
If the patient is a minor or is not legally competent to provide consent, the signature of a parent, guardian, or legal representative is required
Signature of Parent, Guardian, or Legal Representative

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Name (Parent, Guardian, or Legal Representative)

First NameLast Name
Relationship to Patient (Parent, Guardian, or Legal Representative)
Effective Date

MonthDayYear
Date
Should be Empty:

	Yes	1st Use	How Often	Amt Used	Route	Duration	Last Used	Consequences/Effects of Use
Alcohol
Amphetamines (e.g., Adderall, Ritalin)
Anabolic Steroids
Barbiturates
Benzodiazepines
Cocaine
Designer Drugs (e.g., GHB, Spice/K2, Bath Salts)
Diet Pills/Laxatives
Fentanyl
Hallucinogens (Angel Dust, Ecstasy, LSD, Mushrooms, Ketamine, MDMA)
Heroin
Inhalants (Paint, Nitrous Oxide)
Kratom
Marijuana/Hashish
Methadone
Methamphetamine
Muscle Relaxants (misused)
Opiates (e.g., Codeine, Morphine)
Over-the-counter Medications (e.g., Cough Syrup)
Pain Killers (not as prescribed)
PCP (Phencyclidine)
Stimulants (pills)
Synthetic Cannabinoids (e.g., JWH-018, JWH-073)

ADULT BEHAVIORAL HEALTH INTAKE FORM

Patient Information

Contact Information

Emergency Contact

Reason(s) for Consultation

Current Symptom(s)

Medical History

Allergies

Non-Psychiatric Medications

Past Medical History

Request for EKG Results

Exercise Level

SUICIDE RISK ASSESSMENT

Psychiatric History

Trauma/Abuse History

Current Psychiatric Medications

Past Psychiatric Medications

Substance Use History

ADHD Evaluation & Treatment History

Family Background and Childhood History:

Social History

Family Medical History

Family Psychiatric History

Treatment Authorization

Electronic Signatures

If the patient is a minor or is not legally competent to provide consent, the signature of a parent, guardian, or legal representative is required