New Adult Patient Intake

1
Name* This field is required.
First Name
Middle Name (optional)
Last Name
2
Phone Number* This field is required.
Area Code
Phone Number
3
Age* This field is required.
4
Date of Birth* This field is required.
Date
Month
Day
Year
5
Please describe your goals for treatment: * This field is required.(Ex: If treatment was successful in what ways would you be able to tell?)
6
Please describe what factors or events have lead to you seeking treatment at this specific time:* This field is required.
7
Please specify your race.
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
8
Please indicate your current relationship status.* This field is required.
Single (never married)
Married
Divorced
Widowed
Separated
Engaged
9
Relationship Information * This field is required.
Name of current spouse/ significant other
Years married/ together:
Name of previous spouse
Years married:
Name of previous spouse
Years married:
10
Please indicate the current marital status of your parents.* This field is required.Check all that apply.
Never Married
Divorced
Currently Married
Mother Remarried
Father Remarried
11
Please describe your current relationship with your mother.* This field is required.Check all that apply.
Good
Mixed
Poor
Never Present
Deceased
12
If your mother is deceased, how long has it been and how old were you?* This field is required.Ex: It has been 3 years and I was 32 years old.
13
Please describe your current relationship with your father.* This field is required.Check all that apply.
Good
Mixed
Poor
Never Present
Deceased
14
If your father is deceased, how long has it been and how old were you?* This field is required.Ex: It has been 3 years and I was 32 years old.
15
At what age did you leave home?* This field is required.
16
What was your reason for leaving home?* This field is required.Select all that apply.
School/College
Poor Home Environment
Got Married
Needing Independence
Other
17
Childhood Information* This field is required.Select all that apply.
Outstanding Home Environment
Normal Home Environment
Chaotic or Poor Home Environment
Witnessed Abuse
Experienced Abuse
Moved Often
Neglected
Traumatic Events
Did Not Live With Parents
Foster Care
Homelessness
Other
18
Support System* This field is required.Please choose all that apply.
Supportive Friends
No or Few Friends
Unsupportive Friends
Substance-use-based Friends
Supportive Family
Unsupportive Family
Distant from Family
Supportive Significant Other
Unsupportive Significant Other
19
Sexual History* This field is required.Please choose all that apply.
Homosexual
Bisexual
Heterosexual
Other
20
Social History* This field is required.Please choose all that apply.
Enjoy Volunteering
Member of A Church
Attend Church Groups
Attend Support Groups
Friends
Attend Goodwill or Other Day Service
Other
21
Do you have any children?* This field is required.
YESNO
22
Children Please list information about all of your children
23
Do you have any siblings?* This field is required.
YESNO
24
Birth Order* This field is required.I am the _____ (st/nd/rd/th) sibling in a line of _____ siblings.
Ex: I am the 1st sibling in a line of 3 siblings.
25
Sibling Information
26
Current Living Arrangements* This field is required.Please choose all that currently apply.
Housing Adequate
Overcrowded
Homeless
Dysfunctional
Dependent On Others For Housing
27
Please list all persons currently living in household.* This field is required.
28
Have you had any previous counseling or medication treatment?* This field is required.
YESNO
29
If yes: who did you see, was it beneficial, and what was the reason for termination?* This field is required.Please list all past care.
30
Have you had previous inpatient treatment?* This field is required.
YESNO
31
If yes: when, was it beneficial, and at what facility?* This field is required.Please list all previous care.
32
Mental Health SymptomsPlease indicate the symptoms you are CURRENTLY experiencing and HOW LONG you have experienced them
Just recently
In the last year
Several Years
Most of my life
Never
Low energy
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Depression
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Waking up in the night
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Trouble falling asleep
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Sleeping too much
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Low self-esteem
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Self-Harm
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Crying often
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Feelings of guilt
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Feeling worthless
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Loss of interest
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Withdrawing from others
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Anxiety/ Fears
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Worries/ Mind racing
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Repeating actions
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Loss of focus
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Hyper- too much energy
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Moodiness
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Difficulty Concentrating
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Anger/Temper Issues
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Physical chronic pain
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Weight change
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Appetite change
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Stomach Issues
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Frequent headaches
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Constipation/Diarrhea
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Gambling Issues
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Financial Stress
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Substance Abuse Issues
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Sexual problems
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Nightmares
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Family Violence
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Physical Abuse
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Sexual Abuse
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Inappropriate Sexual Behaviors
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Perpetrator of Abuse
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Employment Issues
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Troubles at School
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Parent/Child conflict
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Relationship Issues
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Family conflict
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Low energy
Depression
Waking up in the night
Trouble falling asleep
Sleeping too much
Low self-esteem
Self-Harm
Crying often
Feelings of guilt
Feeling worthless
Loss of interest
Withdrawing from others
Anxiety/ Fears
Worries/ Mind racing
Repeating actions
Loss of focus
Hyper- too much energy
Moodiness
Difficulty Concentrating
Anger/Temper Issues
Physical chronic pain
Weight change
Appetite change
Stomach Issues
Frequent headaches
Constipation/Diarrhea
Gambling Issues
Financial Stress
Substance Abuse Issues
Sexual problems
Nightmares
Family Violence
Physical Abuse
Sexual Abuse
Inappropriate Sexual Behaviors
Perpetrator of Abuse
Employment Issues
Troubles at School
Parent/Child conflict
Relationship Issues
Family conflict
Just recently
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In the last year
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Several Years
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Most of my life
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Never
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Just recently
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In the last year
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Several Years
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Most of my life
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Never
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Just recently
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In the last year
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Several Years
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Most of my life
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Never
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Just recently
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In the last year
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Several Years
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Most of my life
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Never
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Just recently
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In the last year
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Several Years
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Most of my life
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Never
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Just recently
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In the last year
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Several Years
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Most of my life
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Never
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Just recently
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In the last year
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Several Years
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Most of my life
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Never
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Just recently
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In the last year
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Several Years
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Most of my life
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Never
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Just recently
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In the last year
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Several Years
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Most of my life
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Never
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Just recently
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In the last year
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Several Years
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Most of my life
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Never
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Just recently
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In the last year
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Several Years
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Most of my life
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Never
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Just recently
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In the last year
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Several Years
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Most of my life
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Never
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Just recently
Row 12, Column 0
In the last year
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Several Years
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Most of my life
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Never
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Just recently
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In the last year
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Several Years
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Most of my life
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Never
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Just recently
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In the last year
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Several Years
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Most of my life
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Never
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Just recently
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In the last year
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Several Years
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Most of my life
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Never
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Just recently
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In the last year
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Several Years
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Most of my life
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Never
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Just recently
Row 17, Column 0
In the last year
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Several Years
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Most of my life
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Never
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Just recently
Row 18, Column 0
In the last year
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Several Years
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Most of my life
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Never
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Just recently
Row 19, Column 0
In the last year
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Several Years
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Most of my life
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Never
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Just recently
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In the last year
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Several Years
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Most of my life
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Never
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Just recently
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In the last year
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Several Years
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Most of my life
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Never
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Just recently
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In the last year
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Several Years
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Most of my life
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Never
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Just recently
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In the last year
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Several Years
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Most of my life
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Never
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Just recently
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In the last year
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Several Years
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Most of my life
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Never
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Just recently
Row 25, Column 0
In the last year
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Several Years
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Most of my life
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Never
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Just recently
Row 26, Column 0
In the last year
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Several Years
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Most of my life
Row 26, Column 3
Never
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Just recently
Row 27, Column 0
In the last year
Row 27, Column 1
Several Years
Row 27, Column 2
Most of my life
Row 27, Column 3
Never
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Just recently
Row 28, Column 0
In the last year
Row 28, Column 1
Several Years
Row 28, Column 2
Most of my life
Row 28, Column 3
Never
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Just recently
Row 29, Column 0
In the last year
Row 29, Column 1
Several Years
Row 29, Column 2
Most of my life
Row 29, Column 3
Never
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Just recently
Row 30, Column 0
In the last year
Row 30, Column 1
Several Years
Row 30, Column 2
Most of my life
Row 30, Column 3
Never
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Just recently
Row 31, Column 0
In the last year
Row 31, Column 1
Several Years
Row 31, Column 2
Most of my life
Row 31, Column 3
Never
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Just recently
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In the last year
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Several Years
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Most of my life
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Never
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Just recently
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In the last year
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Several Years
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Most of my life
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Never
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Just recently
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In the last year
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Several Years
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Most of my life
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Never
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Just recently
Row 35, Column 0
In the last year
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Several Years
Row 35, Column 2
Most of my life
Row 35, Column 3
Never
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Just recently
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In the last year
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Several Years
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Most of my life
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Never
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Just recently
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In the last year
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Several Years
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Most of my life
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Never
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Just recently
Row 38, Column 0
In the last year
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Several Years
Row 38, Column 2
Most of my life
Row 38, Column 3
Never
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Just recently
Row 39, Column 0
In the last year
Row 39, Column 1
Several Years
Row 39, Column 2
Most of my life
Row 39, Column 3
Never
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Just recently
Row 40, Column 0
In the last year
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Several Years
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Most of my life
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Never
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Diagnosis History Please indicate if you or a family member has been diagnosed with any of the following:
Myself
Parent
Grandparent
Sibling
Child
Depression
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Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Anxiety
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Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
ADD/ADHD
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Row 2, Column 3
Row 2, Column 4
PTSD
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Row 3, Column 3
Row 3, Column 4
Autism
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Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Conduct Disorder
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Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Eating Disorders
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Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Schizophrenia
Row 7, Column 0
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Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Substance Abuse Disorder
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Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Personality Disorders
Row 9, Column 0
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Row 9, Column 2
Row 9, Column 3
Row 9, Column 4
Obsessive Compulsive Disorder
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Row 10, Column 2
Row 10, Column 3
Row 10, Column 4
Bipolar Disorder
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Row 11, Column 2
Row 11, Column 3
Row 11, Column 4
Learning Disorders
Row 12, Column 0
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Row 12, Column 2
Row 12, Column 3
Row 12, Column 4
Infertility
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
Row 13, Column 3
Row 13, Column 4
Depression
Anxiety
ADD/ADHD
PTSD
Autism
Conduct Disorder
Eating Disorders
Schizophrenia
Substance Abuse Disorder
Personality Disorders
Obsessive Compulsive Disorder
Bipolar Disorder
Learning Disorders
Infertility
Myself
Row 0, Column 0
Parent
Row 0, Column 1
Grandparent
Row 0, Column 2
Sibling
Row 0, Column 3
Child
Row 0, Column 4
Myself
Row 1, Column 0
Parent
Row 1, Column 1
Grandparent
Row 1, Column 2
Sibling
Row 1, Column 3
Child
Row 1, Column 4
Myself
Row 2, Column 0
Parent
Row 2, Column 1
Grandparent
Row 2, Column 2
Sibling
Row 2, Column 3
Child
Row 2, Column 4
Myself
Row 3, Column 0
Parent
Row 3, Column 1
Grandparent
Row 3, Column 2
Sibling
Row 3, Column 3
Child
Row 3, Column 4
Myself
Row 4, Column 0
Parent
Row 4, Column 1
Grandparent
Row 4, Column 2
Sibling
Row 4, Column 3
Child
Row 4, Column 4
Myself
Row 5, Column 0
Parent
Row 5, Column 1
Grandparent
Row 5, Column 2
Sibling
Row 5, Column 3
Child
Row 5, Column 4
Myself
Row 6, Column 0
Parent
Row 6, Column 1
Grandparent
Row 6, Column 2
Sibling
Row 6, Column 3
Child
Row 6, Column 4
Myself
Row 7, Column 0
Parent
Row 7, Column 1
Grandparent
Row 7, Column 2
Sibling
Row 7, Column 3
Child
Row 7, Column 4
Myself
Row 8, Column 0
Parent
Row 8, Column 1
Grandparent
Row 8, Column 2
Sibling
Row 8, Column 3
Child
Row 8, Column 4
Myself
Row 9, Column 0
Parent
Row 9, Column 1
Grandparent
Row 9, Column 2
Sibling
Row 9, Column 3
Child
Row 9, Column 4
Myself
Row 10, Column 0
Parent
Row 10, Column 1
Grandparent
Row 10, Column 2
Sibling
Row 10, Column 3
Child
Row 10, Column 4
Myself
Row 11, Column 0
Parent
Row 11, Column 1
Grandparent
Row 11, Column 2
Sibling
Row 11, Column 3
Child
Row 11, Column 4
Myself
Row 12, Column 0
Parent
Row 12, Column 1
Grandparent
Row 12, Column 2
Sibling
Row 12, Column 3
Child
Row 12, Column 4
Myself
Row 13, Column 0
Parent
Row 13, Column 1
Grandparent
Row 13, Column 2
Sibling
Row 13, Column 3
Child
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Suicide Risk Screen* This field is required.If there is currently any suicide risk please seek help and call the National Suicide Hotline at 1-800-273-8255
None
Yes, Recently
Yes, In the past
Suicidal Thoughts?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Suicidal Attempts?
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Suicidal Threats?
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Suicidal Thoughts?
Suicidal Attempts?
Suicidal Threats?
None
Row 0, Column 0
Yes, Recently
Row 0, Column 1
Yes, In the past
Row 0, Column 2
None
Row 1, Column 0
Yes, Recently
Row 1, Column 1
Yes, In the past
Row 1, Column 2
None
Row 2, Column 0
Yes, Recently
Row 2, Column 1
Yes, In the past
Row 2, Column 2
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35
If you responded "yes" to any of the previous questions please explain the nature of the thoughts, attempts, and/or threats.* This field is required.If you responded "none" to all questions please write n/a.
36
Do you currently use drugs or drink alcohol?* This field is required.(This includes social drinking and any prescription drug not prescribed to you)
YESNO
37
Have you ever felt you should cut down on your drinking or drug use?
YESNO
38
Have friends or family annoyed you by criticizing your drinking or drug use?
YESNO
39
Have you ever felt bad or guilty about your drinking or drug use?
YESNO
40
Have you ever drank or used drugs in the morning to steady or your nerves or get rid of a hangover?
YESNO
41
Have your relationships with friends or family members been negatively influenced by your drinking or drug use?
YESNO
42
Have you served or are you currently serving in the military?* This field is required.
YESNO
43
Military Information* This field is required.
Please Select
Please Select
Currently serving
Honorably discharged
Dishonorably discharged
Other than honorably (OTH) discharged
General discharge
Bad conduct discharge
Please choose an option that applies to you
How many years did you serve?
44
Please specify your current employment/disability status.* This field is required.
Employed
Disabled for A Physical Condition
Disabled for A Mental Disability
Disabled for Both Physical and Mental Disabilities
Unemployed With No Disability
None of these
45
Current Employer Information* This field is required.
Who is your current employer?
What is your current position at your job?
46
How long have you been unemployed/disabled?* This field is required.
47
Legal Information* This field is required.Please choose all that apply.
No Legal History
Substance Related Charges
Court Ordered Therapy
Felony Charges
Domestic/Assault Charges
Arrested
Jail Time Served
Currently On Parole or Probation
48
How many times have you been arrested?* This field is required.
49
How many times have you served jail time? * This field is required.
50
What is the name of your probation officer? * This field is required.
First Name
Last Name
51
Did/do you have any learning disabilities?* This field is required.
YESNO
52
Did you participate in a Special Education program?* This field is required.
YESNO
53
Did you attend an Alternative School?* This field is required.
YESNO
54
What was the name of the Alternative School?* This field is required.
55
Were you ever expelled, suspended, or retained?* This field is required.
YESNO
56
What was the last grade you completed?* This field is required.
57
School Information* This field is required.
Name of High School Attended
Please Select
Please Select
Yes, obtained diploma
Not completed
GED obtained
Completed?
Name of High School Attended
Please Select
Please Select
Yes, obtained diploma
Not completed
GED obtained
Completed?
Name of College Attended
Degree Obtained
Name of College Attended
Degree Obtained
58
Developmental Milestones* This field is required.
Above Average (ex: walked and talked before most)
Average (ex: walked and talked at the same level as peers)
Below Average (ex: walked and talked later than most)
I am not sure.
59
Do you smoke?* This field is required.
YESNO
60
How much do you smoke per day?* This field is required.
61
Have you or any family members been diagnosed with any of the following:
Myself
Parent
Child
Grandparent
Diabetes
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Head Injury/TBI
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Thyroid Disease
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
HIV/AIDS
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Stroke
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Birth Defects
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Cancer
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Heart Disease
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
High Blood Pressure
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Alzheimer's/Dementia
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Diabetes
Head Injury/TBI
Thyroid Disease
HIV/AIDS
Stroke
Birth Defects
Cancer
Heart Disease
High Blood Pressure
Alzheimer's/Dementia
Myself
Row 0, Column 0
Parent
Row 0, Column 1
Child
Row 0, Column 2
Grandparent
Row 0, Column 3
Myself
Row 1, Column 0
Parent
Row 1, Column 1
Child
Row 1, Column 2
Grandparent
Row 1, Column 3
Myself
Row 2, Column 0
Parent
Row 2, Column 1
Child
Row 2, Column 2
Grandparent
Row 2, Column 3
Myself
Row 3, Column 0
Parent
Row 3, Column 1
Child
Row 3, Column 2
Grandparent
Row 3, Column 3
Myself
Row 4, Column 0
Parent
Row 4, Column 1
Child
Row 4, Column 2
Grandparent
Row 4, Column 3
Myself
Row 5, Column 0
Parent
Row 5, Column 1
Child
Row 5, Column 2
Grandparent
Row 5, Column 3
Myself
Row 6, Column 0
Parent
Row 6, Column 1
Child
Row 6, Column 2
Grandparent
Row 6, Column 3
Myself
Row 7, Column 0
Parent
Row 7, Column 1
Child
Row 7, Column 2
Grandparent
Row 7, Column 3
Myself
Row 8, Column 0
Parent
Row 8, Column 1
Child
Row 8, Column 2
Grandparent
Row 8, Column 3
Myself
Row 9, Column 0
Parent
Row 9, Column 1
Child
Row 9, Column 2
Grandparent
Row 9, Column 3
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Are you currently taking any medications?* This field is required.
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Medication List* This field is required.Please list any and all medication you are currently taking including over the counter medications
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Are you allergic to any medications?* This field is required.
YESNO
65
Please list all allergies and reactions.* This field is required.
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* This field is required.(You can ask for a copy of these Terms, Conditions, and Client Rights and Responsibilities at any time)
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DateForm Completed on:
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