Mental Health Intake Form

Mental Health Intake Form
Childs Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Parents Name

First NameLast Name
Parents Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parents Email
example@example.com
Parents Date of Birth

MonthDayYear
Date
Gender
Primary Care Physician

First NameLast Name
Medical History
List all current prescription medications and how often you take them
Current medical problems
Past medical problems, nonpsychiatric hospitalization, or surgeries
Psychiatric History:
Outpatient treatment
If yes, Please describe when, by whom, and nature of treatment
Psychiatric Hospitalization
If yes, Please describe when, by whom, and nature of treatment
Past Psychiatric Medications

If you have ever taken any of the following medications, please indicate the dates and daily dosage.

Rows	Have you ever taken it?	Dates	Dosage	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)
Clozaril (clozapine)
Haldol (haloperidol)
Prolixin (fluphenazine)
Risperdal (risperidone)
Ambien (zolpidem)
Sonata (zaleplon)
Rozerem (ramelteon)
Restoril (temazepam)
Desyrel (trazodone)
Adderall (amphetamine)
Concerta (methylphenidate)
Ritalin (methylphenidate)
Strattera (atomoxetine)
Xanax (alprazolam)
Ativan (lorazepam)
Klonopin (clonazepam)
Valium (diazepam)
Tranxene (clorazepate)
Buspar (buspirone)

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?
Additional information
T-shirt Size
Emergency Contact

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Please
Current Symptoms

Other
Signature
Should be Empty: