Intake Questionnaire For New Patients (Adult)

Intake Questionnaire For New Patients (Adult)

This questionnaire is for the purpose of getting to know you better in order to provide the best possible mental health services. Please complete this form as honestly and completely as possible. All information that you provide us will be confidential as required by state and federal law.
Date

MonthDayYear
SSN
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Age
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Alternate Number
Marital Status

singlemarriedseparateddivorcedremarriedengagedwidowedcohabiting
If applicable, please complete the following
Partner’s Name

First NameLast Name
Partner’s Age

IF YOU HAVE CHILDREN PLEASE LIST THEIR NAMES AND AGES

WHO CURRENTLY LIVES IN YOUR RESIDENCE (adults and children)

Education

	Answers
Highest grade level completed:
Degree obtained, if applicable:
Did you have any disciplinary problems in school?
If yes, please explain:
Were you considered hyperactive/ADHD in school?
If yes, were/are you on any medication?
If so, which medication?
What kinds of grades did you get in school?

Employment History (most recent first)

Alcohol

	Answer Correctly
Do you drink alcohol?
If yes, age of first use
How much do you drink?
How often do you drink?
Have you ever passed out from drinking?
How often?
Have you ever blacked out from drinking?
How often?
Have you ever had the “shakes”?
How often?
Have you ever felt you should cut down on your drinking/drug use?
Have people annoyed you by criticizing your drinking/drug use?
Have you ever felt bad or guilty about your drinking/drug use?
Have you ever drank/used drugs in the morning to steady your nerves or relieve a hangover?
Do you use tobacco?
If yes, how often?

Please indicate for each drug listed below

The Holmes-Rahe Scale

Read each of the events listed below, and check the box next to any even which has occurred in your life in the lasttwo (2) years. There are no right or wrong answers. The aim is to identify which of these events you have experienced lately.

LIFE EVENTS	LIFE CRISIS UNIT	LIVE EVENTS	LIVE CRISIS UNIT
Death of Spouse	100	Change in schools	20
Son or daughter leaving home	29	Pregnancy	40
Divorce	73	Change in recreation	19
Trouble with in-laws	29	Sexual Difficulties	39
Marital Separation	65	Change in church activities	19
Outstanding personal achievement	28	Gain of new family member	39
Gone to jail	63	Change in social activities	18
Spouse begins or stops work	26	Business readjustment	39
Death of close family member	63	Mortgage or loan less than $30,000	17
Begin or end school	26	Change in financial state	38
Personal injury or illness	53	Change in sleeping habits	16
Change in living conditions	25	Death of a close friend	37
Marriage	50	Change in number of family gettogethers	15
Revision in personal habits	24	Change to different line of work	36
Fired at work	47	Change in eating habits	15
Trouble with boss	23	Increase in arguments withspouse	35
Marital reconciliation	45	Vacation	13
Change in work hours or conditions	20	Mortgage over $100,000	31
Retirement	45	Christmas alone	12
Change in residence	20	Foreclosure of mortgage or loan	30
Change in health of familymember	44	Minor violations of the law	11
Change in responsibilities at work	29

	Medication	Dosage	How long have you been taking it?	Has it been helpful?
1
2
3
4

	Medication	Dosage	How long have you been taking it?	Has it been helpful?
1
2
3
4

Symptoms