Narrative Intake

Date

Name

First nameLast Initial

Email

example@example.com

I'd like to be called: Chosen Name

Date of Birth

Date

Client Type

Other

Presenting Situation - Why are you here? Why today?

5 first thoughts about your current situation

Specific Feelings and Behaviors related to the presenting situation

History of Presenting Situation - How long has this been going on? Has it gotten better or worse over time?

Goals of our sessions together?

Mental Health History- Are you seeing any other providers currently? In the past? Have you ever been diagnosed with a mental illness? If so, what was the diagnosis, and by whom? What was the outcome? What was the experience like?

Has a mental health or medical provider diagnosed you with any of the following for which you receive mental health or psychiatric treatment?

Are you on any medications for mental health reasons? If so, what? What dosage? How often? And where do you get this medication?

Have you EVER tested positive for COVID or think you may have had COVID without testing positive?

Medical History - Are you dealing with or have you dealt with any medical situations that might be currently affecting your mental well-being?

Please select any that may apply

Contraindications

Ketamine is contraindicated in patients with underlying conditions in which increased blood pressure would pose a risk of complications such as aortic dissection, uncontrolled hypertension, myocardial infarction, or aneurysms.

It is contraindicated in those who have shown prior hypersensitivity to the drug.
It is not recommended for use during obstetrics, pregnancy, or breastfeeding, as it is unknown if this medication passes into breast milk.
Care must be used in patients who are intoxicated with ethanol due to additive sedation.
It is contraindicated in patients with borderline personality disorder, or schizophrenia due to the potential for exacerbating the underlying condition.

Are you currently on any other medications? What? What is the dose? How often do you take it? Where do you get this medication?

Have you had any experiences with psychedelic medicine work? What was the medicine? Dose? Setting? How was this experience?

Sleep, Nutrition and Exercise - How are you sleeping? How do you eat? Do you get enough to eat? How would you describe your physical fitness? What would you improve?

Sexual Health - When was your last STI screening? Do you have access to birth control? Is pregnancy affecting your life? Are you dealing with any sexual health issues that might be currently affecting your mental well-being?

Alcohol and Drug Use- How does your current alcohol or drug use affect your current mental well-being?

Family Medical History, Mental Health History, Alcohol and Drug History

Family of Origin- Who raised you? Who did you grow up with? Are your past or current family conflicts currently affecting your mental well-being?

Current Family / Living Situation - Who do you live with? For how long? Is your living situation safe? Stable?

Social Support- How is your social support? Who do you turn to for emotional support? Do you feel isolated?

Financial Situation - Are you able to support yourself? Is your financial situation currently affecting your mental well being?

How have you experienced discrimination?

Do you have any legal problems that may be currently affecting your current mental well-being?

Do you have a firearm in your home?

Other

Recreation & Pleasurable Activities - What do you do for fun? Who do you do it with? Are there activities you used to enjoy but lost interest in? Why?

Personal Philosophy- How would you describe your personal philosophical, religious or spiritual beliefs? Were you raised in any particular faith or belief system that might be currently affecting your mental well-being? Have you ever had what you would describe as a "mystical experience", "ego death", or "Near Death Experience"?

Sexuality- How is your sex life fulfilling? How does your sex life affect your current mental well-being?

3 Biggest Current Struggles

3 Biggest Resources / Sources of Strength