CareForce Intake Form

  • PERSONAL INFORMATION

  • Today's Date :
     - -
  • Date Of Birth :*
     - -
  • Format: (000) 000-0000.
  • Sex
  • Status :
  • Do you have children? :
  • Are You A Retiree? :
  • Military

  • EMERGENCY CONTACT

  • Format: (000) 000-0000.

  • HOW CAN WE SERVE YOU?

  • Clinical Services
  • Wellness & Lifestyle
  • Primary & Preventative Care

  • PRESENTING PROBLEM

  • Check the following symptoms that you are experiencing:
  • Check the following symptoms that you are experiencing:

  • MENS HEALTH SCREENING

    Skip to next set of screening questions if not applicable.
  • Do you frequently experience low energy, decreased motivation, or reduced muscle strength?
  • Have you ever/currently received hormone replacement therapy?
  • Have you noticed changes in sexual function, mood, confidence, or libido that impact your well being?
  • Are you interested in learning more about our Men's Health Program or Testosterone Replacement Therapy?

  • MEDICAL HX

  • Medical Conditions

  • Directions: Check ✓ if applicable to you or family member, whether past or current
  • Immune/Viral Allergies:
  • Allergies:
  • Asthma
  • Autoimmune
  • Cancer
  • Hep A/B/C/D
  • HIV/AIDS
  • Womens Health
  • PCOS
  • Pregnancy Cond'ts
  • Menstrual Cycle Irregularities
  • Hysterectomy
  • Miscarriage
  • Endocrine
  • Thyroid
  • Diabetes
  • Insulin Resistant
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  • PSYCHIATRIC | MENTAL HEALTH HX

  • List any current or past psychiatric or mental health treatment, conditions, diagnoses, outpatient or inpatient facilities for Psychiatric Mental Health Treatment or Counseling:

  • Has a family member ever been diagnosed with a mental health disorder?
  • Did you have any developmental delays, cognitive irregularities, or early childhood concerns?

  • TRAUMA, LOSS, SIGNIFICANT EVENT HX

  • Checkmark ✓ if you have experienced any of the following as a child or adult. Briefly explain if you can. We know this is sensitive, thank you for sharing so that we may assist you better.
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  • RISK ASSESSMENT

  • OTHER AREAS

  • Do you wish to harm yourself?*
  • Do you partake in risky sexual behavior?
  • Do you wish to harm others?*
  • Do you have concerns of phone/technology dependency?
  • Any History of Self Harm?
  • Do you have concerns about over or under eating?
  • Do you feel safe, currently?
  • Do you have concerns about gambling behavior?
  • History of overspending money?

  • SUBSTANCE USE

  • Do you currently use substances in moderation?
  • Have you ever overused substances?
  • Does tobacco, alcohol, or drugs help to cope with life or particular symptom?
  • Would others think or say the same of you?

  • SUBSTANCE ABUSE & ADDICTION

  • Self-Assessment Directions: check "Yes/No" for each true statement of you within 12 months.

  • I have used opioids or substances (prescription or illicit pills, fentanyl, heroin, Percocet, Oxy, Vicodin, cocaine, alcohol, benzos, etc), or other problem behavior in the last 30 days.*
  • I take opioids, substances, alcohol, or other behavior, in excess & more than intended, and find I need more and more to have the same effect.*
  • I have tried to stop, but I experience withdrawal symptoms (e.g., nausea, sweating, anxiety, muscle pain, obsessive thoughts) when I stop or reduce opioid, substance use, or other behavior.*
  • Opioid, substance use, or behavior interferes with my ability to work, care for my family, or maintain relationships. Despite problems, I continue to use.*
  • The substance use or behavior is expensive and takes time. I miss out of other things in life. Sometimes it's dangerous.*
  • I have been prescribed Suboxone or other treatment before and am ready for a reliable provider who cares.*

  • SUBSTANCE ABUSE HX

  • Fill out the chart as best as you can
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  • FAMILY HX

  • EMERGENCY HX

  • Any history of ambulatory or emergency related to substance abuse (Example: overdose)?
  • Date:
     - -

  • OPIOID ADDICTION

  • Are you currently taking buprenorphine/Suboxone?*
  • Do you have an active prescription for buprenorphine/Suboxone?*
  • Do you currently take buprenorphine/Suboxone without an active prescription?*

  • TREATMENT HX

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  • HISTORY ASSESSMENT

  • TRIGGERS & COPING

  • SUPPORT & GOALS

  • Between 0-8, rate your readiness to change. (0=Not ready, 8=Extremely ready)
  • Counseling Needs:
  • Frequency:

  • SOCIAL HX

  • UPBRING

  • Raised by:
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  • Did you meet developmental milestones (YES) on time or did you experience any delays (NO) in your childhood?
  • Were there any significant events in your childhood (e.g., loss, neglect, abuse, instability) that you feel still affect you today? Can you please explain?

  • CURRENT RELATIONSHIPS

  • Who is your support system? Check those currently in your life that you would say you have a healthy and supportive relationship with:
  • Any current family or relationship stressors?

  • SPIRITUAL

  • Are spiritual beliefs important to your treatment or healing?

  • STRENGTHS AND GOALS

  • Personal Strengths or what others have described you as:
  • Are you satisfied with your career/job:

  • LEGAL HISTORY

  • Any Involvement in the legal system:*
  • Are You Currently on Parole or Probation?

  • 5 PILLARS OF WELLNESS

  • Self-Assessment: Take a moment to reflect on your current state of health in each of the core pillars: Physical, Mental, Spiritual, Relational/Social and Practical. 

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  • CareForce Wellness
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