CareForce Intake Form

  • PERSONAL INFORMATION

  •  - -
  •  - -
  • Format: (000) 000-0000.

  • EMERGENCY CONTACT

  • Format: (000) 000-0000.

  • HOW CAN WE SERVE YOU?

  • PRESENTING PROBLEM

  • MENS HEALTH SCREENING

    Skip to next set of screening questions if not applicable.

  • MEDICAL HX

  • Medical Conditions

  • Directions: Check ✓ if applicable to you or family member, whether past or current
  • Immune/Viral Allergies:
  • Womens Health
  • Endocrine
  • Rows
  • Rows
  • Rows

  • 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:

  • 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.
  • Rows

  • RISK ASSESSMENT

  • OTHER AREAS

  • SUBSTANCE USE

  • SUBSTANCE ABUSE & ADDICTION

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

  • SUBSTANCE ABUSE HX

  • Fill out the chart as best as you can
  • Rows

  • FAMILY HX

  • EMERGENCY HX

  •  - -

  • OPIOID ADDICTION

  • TREATMENT HX

  • Rows

  • HISTORY ASSESSMENT

  • TRIGGERS & COPING

  • SUPPORT & GOALS

  • SOCIAL HX

  • UPBRING

  • Rows

  • CURRENT RELATIONSHIPS

  • SPIRITUAL

  • STRENGTHS AND GOALS

  • LEGAL HISTORY

  • 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. 

  • Rows
  • Image field 175
  • CareForce Wellness
  •  
  • Should be Empty: