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.
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*

YesNo
If yes, Please describe when, by whom, and nature of treatment*
Psychiatric Hospitalization*

YesNo
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.

	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:*

Bipolar disorderDepressionAnxietyAngerSuicideSchizophreniaPost-traumatic stressAlcoholabuseNoneOther
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*

SmallMediumLargeXL2XL3XL
Emergency Contact*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Please*

After School ProgramSummer ProgramMentoring ProgramGun & Gang Violence Program
Current Symptoms*

Depressed moodRacing thoughtsExcessive worryUnable to enjoy activitiesImpulsivityAnxiety attacksSleep pattern disturbanceIncrease risky behaviorAvoidanceLoss of interestIncreased libidoHallucinationsConcentration/forgetfulnessDecrease need for sleepSuspiciousnessChange in appetiteExcessive energyExcessive guiltIncreased irritabilityFatigueCrying spellsDecreased libidoN/AOther
Signature*

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