Thrive Mind & Wellness Center
We're honored you've chosen us to support you on your journey toward wellness. Please take a few minutes to complete this intake form so we can better understandyour needs and provide you with the best possible care.
Full Name
*
First Name
Middle Initial
Last Name
Date of Birth - Month
*
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Month
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Day
Year
Date Picker Icon
Gender
*
Primary Care Physician Name
Primary Care Physician Phone Number
Format: (000) 000-0000.
Current Therapist/Counselor Phone Number
Format: (000) 000-0000.
Psychiatrist/Psychiatric NP Name
Emergency Contact and Notes
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Format: (000) 000-0000.
Emergency Contact Relationship
*
Emergency Contact City
Emergency Contact Preferred Language
Additional Notes for Provider and Emergency Contacts
Current Symptoms and Safety
Current symptoms
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Depressed mood
Racing thoughts
Excessive worry
Unable to enjoy activities
Impulsivity
Trouble sleeping
Panic attacks
Current symptoms
Irritability
Mood swings
Low energy
Poor concentration
Appetite changes
Social withdrawal
Flashbacks
Nightmares
Anger outbursts
Other
Has the patient had thoughts of suicide or self-harm recently?
*
If yes, please describe the thoughts, frequency, and any triggers.
Rate the current safety concern on a scale of 1 to 10
*
Weight
Height
Medical and Psychiatric History
Current Medical Problems
Current Medications
Past Medical Problems
Have you ever received psychiatric treatment?
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Yes
No
If yes, please describe the psychiatric treatment received
Have you ever been hospitalized for psychiatric reasons?
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Yes
No
If yes, please provide details of the hospitalization(s)
Family Psychiatric History
Family psychiatric conditions
ADHD/ADD
Bipolar Disorder
Depression
Anxiety
Anger
Suicide
Schizophrenia
Substance Use Disorder
Post-Traumatic Stress Disorder
Eating Disorder
Other Family History
Lifestyle and Substance Use
Exercise Frequency
Exercise Details
Caffeine Intake (cups or servings per day)
Social and Household History
Adopted status
Adopted status
History of divorce or separation
History of abuse
Children in household
History of arrest or legal involvement
Current location
Highest grade completed
Employment status
Employed full-time
Employed part-time
Unemployed
Student
Retired
Self-employed
Homemaker
Unable to work
Marital Status
Partnered
Separated
Divorced
Widowed
Other
Additional information
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