Pinnacle Behavioral Health IPA LLC
2021 Intake Questionnaire
Date of Birth
Briefly, what would you like to discuss with your clinician? Who referred you, or what motivated you to seek assistance?
What are your most distressing symptoms (Ex. anxiety, sleep problems, attention)?
Have you experienced any frequent or intense interest or plan of seriously harming or killing yourself or someone else? Have you ever tried to do something like this in the past? If so please indicate and discuss in detail with your clinician.
Do you drink alcohol often or in large amounts, or use tobacco, marijuana or illegal drugs?
Where and with whom do you presently live? Please list those who are closest to you, and any recent or impending changes in your living situation.
Are you in school? If so, where?
Are you working? If so, where and for how long?
Are you a party to any ongoing legal matter (criminal, family court, divorce, lawsuit)?
Are you requesting paperwork or notification for a third party (Ex. a court hearing, return to or leave from absence from work or school)?
Please list any medical or other health problems that are currently being managed.
Please list the names and dosages of all prescription or over-the-counter medications you regularly take, along with any food or drug allergies.
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Patient Signature validating above answers are truthful and correct to the extent of your knowledge.
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