INTAKE FORM
Identifying Info
Name
*
First Name
Middle Initial
Last Name
Date of Birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
*
Sex Assigned at Birth
*
Male
Female
Gender Identity
*
Male
Female
Bigender
Cisgender
Female to Male (FTM)
Gender Fluid
Gender Non-conforming
Gender Questioning
Gender Queer
Male to Female (MTF)
Pangender
Transgender
Agender
Androgyny/Androgynous
Gender Pronouns
He/him/his
She/her/hers
They/them/theirs
Sexual Orientation
*
Straight
Bisexual
Gay
Pansexual
Asexual
Lesbian
Questioning
Ethnic Background
*
e.g. Irish, Polish, German, African American
Who resides with you?
How did you hear about Dr. Grant?
Phone Number
*
-
Area Code
Phone Number
May Dr. Grant or his associates call, leave a VM and/or text?
*
Yes
No
CURRENT ISSUE
Briefly explain why you are seeking services at this time:
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Have you participated in psychotherapy before?
*
Yes
No
If so, with whom, where, and dates?
And what were you seeking services for?
Have you ever been treated by a psychiatrist or NP?
*
Yes
No
If so, with whom and where?
What were you seeking services for?
Current Psychiatrist or NP's name
First Name
Last Name
Address of Psychiatrist or NP
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number of Psychiatrist or NP
-
Area Code
Phone Number
Fax Number of Psychiatrist or NP
-
Area Code
Phone Number
Has anyone in your family suffered from a mental health or substance abuse issue?
*
Yes
No
If so, whom?
What has your experience been like with healthcare providers?
SYMPTOM CHECKLIST
Check ALL that apply
*
MEDICAL HISTORY
Primary Care Physician's Name
First Name
Last Name
Date of last physical exam
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address of PCP
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number of PCP
-
Area Code
Phone Number
Current Medical Problems
Past Surgical History & Hospitalization(s)
MEDICATIONS/OTC
Include Supplements/Herbs etc.
ADDITIONAL MEDICAL INFO
Have you ever taken psychotropic medication in the past?
*
Yes
No
If so, please describe
Do you or have you participated in Complimentary and Alternative Treatments to Medicine (CAMS)?
*
Yes
No
(e.g. MASSAGE THERAPY, AROMATHERAPY, HERBAL MEDICINE, ACUPUNCTURE, MEDITATION, YOGA, MANIPULATIVE/BODY BASED PRACTICES, DIETARY SUPPLEMENTS, ENERGY THERAPIES)
If so, please describe
Describe your exercise habits
*
How would you describe your overall health?
*
Excellent
Good
Fair
Poor
ALCOHOL & DRUG USE
Age of your first intoxication
*
Do you believe you have a current problem with alcohol or drugs
Yes
No
Have you ever sought treatment for an alcohol or drug problem?
Yes
No
If so, please describe dates, locations and length of treatment
Do you smoke cigarettes, cigars, use pipes or chew tobacco?
Yes
No
Sometimes
If so, please describe use
Do you consume caffeine?
Yes
No
Sometimes
If so, please describe your use
EDUCATION
Name of High School
Highest Grade Completed
Did you attend trade/technical school or college
Yes
No
Name of trade/school
Did you graduate?
Yes
No
Name of trade/school
Did you graduate?
Yes
No
Name of trade/school
Did you graduate?
Yes
No
If not, please explain
Did you participate in any extracurricular activities while in school/college?
Yes
No
If so, please describe
EMPLOYMENT
Current Employer
Title/Occupation
State Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Employer
Title/Occupation
Start Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you held other jobs
*
Yes
No
If so, please describe
Have you ever been fired, laid off or quit a job?
*
Yes
No
If so, please describe
With whom was your longest length of employment?
*
How do you generally get along with bosses, colleagues etc.?
*
Have you ever filed bankruptcy?
*
Yes
No
If so, when?
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you currently have financial stressors?
Yes
No
If so, please describe
FAMILY OF ORIGIN
Where were you born and raised?
*
What was it like growing up? Describe your experience...
*
Did you grow up religious/spiritual?
Yes
No
If so, please describe
If you currently practice, please describe your religious/spiritual practices
Who were you raised by?
*
Are these individual(s) alive?
*
Yes
No
If not alive, how and when did said individual(s) die?
If alive, please describe your current relationship with these individual(s)
Also, please provide details as to their age, residence, employment status/occupation
Of your parents/caretakers, who were you the closest?
*
Do you have siblings?
*
Yes
No
If so, please indicate oldest to youngest and where you are in the birth order
How would you describe your relationship with your siblings?
CURRENT RELATIONSHIPS
Please indicate your current relationship status
Single
Partnered
Married
Divorced
Widowed
Separated
Engaged
Polyamory
Open Relationship
If applicable, please describe the relationship with your partner(s)
Do you have children?
*
Yes
No
If so, please list their names/ages
If applicable, how do you get along with your children/step-children etc.?
SOCIAL HISTORY
Have you ever been arrested?
*
Yes
No
If so, please describe
Please describe how you spend your free time
*
How would others who know you well describe you?
*
In childhood and/or adolescence, were you ever physically, emotionally or sexually abused?
*
Yes
No
As an adult, have you ever been physically, emotionally or sexually abused
*
Yes
No
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