Holistic mental wellness Intake Form

Holistic mental wellness Intake Form
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client Legal Name

First NameLast Name
Client Preferred Name

First NameLast Name
Person making referral

First NameLast Name
Client Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Client Email
example@example.com
Client Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Insurance Provider
Insurance ID #
If you are completing this form for someone other than yourself (referral) you are finished. If services are for yourself please continue filling out the intake.
Front of Insurance Card

Cancelof
Back of Insurance Card

Cancelof
Legal Gender
Primary Care Physician

First NameLast Name
Please list the problem(s) which you are seeking help?
Current Symptoms

Other
Have you ever had feelings or thoughts that you didn't want to live?
Do you currently feel that you don't want to live?
How often do you have these thoughts?
On a scale of 1 to 10, with 10 being the strongest, how intense are your thoughts of self harm or suicide at this moment?

1

2

3

4

5

6

7

8

9

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?

If you have ever taken any of the following medications, please indicate the dates and daily dosage (check all that apply).

Other medications?
Family Psychiatric History
Has anyone in your family been diagnosed with or treated for:

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?
How many times a week do you exercise?
Check if you have ever tried the following

Other
How many caffeinated beverages do you drink a day?
Tobacco History
Have you ever smoked cigarettes?
How many packs per day?
How many years?
Family Background and Childhood History:
Were you adopted?
Where did you grow up?
List your siblings and their ages:
Did your parents divorce?
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:
Are you currently:
Do you have any children?
Please list ages and gender:
Have you ever been arrested?
Additional information
Emergency Contact

First NameLast Name
Phone Number
Format: (000) 000-0000.
Should be Empty:

Medical History