Psychiatric Intake Form
Name
First Name
Last Name
Age
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Occupation
Company Name
Emergency Contact Person
First Name
Last Name
Relationship to the patient
Please Select
Father
Mother
Brother
Sister
Relatives
Guardian
Self
Primary Phone Number of Emergency Contact Person
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number of Emergency Contact Person
Please enter a valid phone number.
Format: (000) 000-0000.
Mental Health Status/History
Weight
Height
What issues or problems are you currently experiencing?
Have you received any counseling or psychiatric sessions before?
Yes
No
If yes, please tell us the reason and when.
Please select the following symptoms you are experiencing
Rows
Mild
Moderate
Severe
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
Judgment errors
Loneliness
Loss of interest in activities
Physical trauma perpetrator
Family Psychiatric History (Do you have a family member who was diagnosed with any of these mental conditions?)
Bipolar disorder
Depression
Anxiety
Anger
Suicide
Schizophrenia
Post-traumatic stress
Alcohol abuse
Other substance abuse
Violence
Other
Are you currently taking any psychiatric medications?
Yes
No
If yes, please tell us the medication name, purpose, and the frequency.
Do you have any allergies?
Yes
No
If yes, please tell us more about it.
If you're experiencing any non-psychiatric medical conditions, please list them below so that we are aware of it.
Are you smoking?
Yes
No
If you have history of drinking alcohol, please explain below how often do you do it?
If you have history of taking illegal substance, kindly elaborate below.
Do you have any suicidal thoughts?
Yes
No
Patient's Signature
*
Date Signed
-
Month
-
Day
Year
Date
Therapist Information
Therapist Name
First Name
Last Name
Therapist Phone Number
Format: (000) 000-0000.
Therapist Email Address
example@example.com
Date Signed
-
Month
-
Day
Year
Date
Insurance Plan
Blue Cross Blue Shield IL
Aetna
United/Optum
Cash
Other Insurance
Insurance Plan Member ID#
Appointment
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Submit
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