Intake Form

Intake Form
James Christopher Bentley, LCSW
www.jamescbentley.com
(901) 316-6542
jamesbentley986@gmail.com
Personal Information
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security Number
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Sex*

MaleFemaleI identify as something different than my birth sex.
Are you currently:*

SingleMarriedPartneredDivorcedWidowed
Are you currently:*

EmployedUnemployedStudentDisabledRetired
Occupation / Employer
Name of Insurance Company*
If none, please type None in all related fields.
ID Number*
Group Number*
Insured's Name*

First NameLast Name
Insured's Date of Birth*

MonthDayYear
Date
Insured's Social Security Number
Insured's Employer*
If possible, please upload a photo of the front and back of your insurance card.

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Secondary Insurance Company
Only need to fill out this section is applicable.
Secondary ID Number
Secondary Group Number
Secondary Insured's Name

First NameLast Name
Secondary Insured's Date of Birth

MonthDayYear
Date
Secondary Insured's Social Security Number
Secondary Insured's Employer
If possible, please upload a photo of the front and back of your secondary insurance card.

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Emergency Contact*

First NameLast Name
Relationship to you*
Phone Number*

Area CodePhone Number
Please list the problem(s) which you are seeking help? *
Current Symptoms*

Depressed moodRacing thoughtsExcessive worryUnable to enjoy activitiesImpulsivityAnxiety attacksSleep pattern disturbanceIncrease risky behaviorAvoidanceLoss of interestIncreased libidoHallucinationsConcentration/forgetfulnessDecrease need for sleepSuspiciousnessChange in appetiteExcessive energyExcessive guiltIncreased irritabilityFatigueCrying spellsDecreased libidoOther
Have you ever had feelings or thoughts that you didn't want to live?*

YesNo
Do you currently feel that you don't want to live?*

YesNo
If yes, how often do you have these thoughts?
Do you feel hopeless and/or worthless?*

YesNo
Have you ever tried to kill or harm yourself?*

YesNo
Medical History
Primary Care Physician*

First NameLast Name
Primary Care Physician's Phone Number

Area CodePhone Number
Previous Therapist / Counselor*

First NameLast Name
Do you have any allergies?*

YesNo
If yes, please list them.
Current Weight*
Current Height*
List all current prescription medications and how often you take them.*
Current medical problems*
Past medical problems, nonpsychiatric hospitalization, or surgeries*
Psychiatric History
Have you ever had outpatient treatment?*

YesNo
If yes, please describe when, by whom, and nature of treatment.
Have you ever had a psychiatric hospitalization?*

YesNo
If yes, please describe when, by whom, and nature of treatment.
Check if you have ever abused the following*

MethamphetamineCocaineStimulants (pills)HeroinLSD or HallucinogensMarijuanaPain killers (not as prescribed)MethadoneTranquilizer/sleeping pillsAlcoholEcstasyNoneOther
Past Psychiatric Medications

If you have ever taken any of the following medications, please indicate the dates and daily dosage. *

		Dates	Dosage	Side Effects?
Prozac (fluoxetine)
Zoloft (sertraline)
Luvox (fluvoxamine)
Paxil (paroxetine)
Celexa (citalopram)
Lexapro (escitalopram)
Effexor (venlafaxine)
Cymbalta (duloxetine)
Wellbutrin(bupropion)
Remeron (mirtazapine)
Serzone (nefazodone)
Anafranil (clomipramine)
Pamelor (nortrptyline)
Tofranil (imipramine)
Elavil (amitriptyline)
Tegretol (carbamazepine)
Lithium
Depakote (valproate)
Lamictal (lamotrigine)
Tegretol (carbamazepine)
Topamax (topiramate)
Seroquel (quetiapine)
Zyprexa (olanzepine)
Geodon (ziprasidone)
Abilify (aripiprazole)
Clozaril (clozapine)
Haldol (haloperidol)
Prolixin (fluphenazine)
Risperdal (risperidone)
Ambien (zolpidem)
Sonata (zaleplon)
Rozerem (ramelteon)
Restoril (temazepam)
Desyrel (trazodone)
Adderall (amphetamine)
Concerta (methylphenidate)
Ritalin (methylphenidate)
Strattera (atomoxetine)
Xanax (alprazolam)
Ativan (lorazepam)
Klonopin (clonazepam)
Valium (diazepam)
Tranxene (clorazepate)
Buspar (buspirone)
I have not taken any of the above medications.

Family Psychiatric History
Has anyone in your family been diagnosed with or treated for:*

Bipolar disorderDepressionAnxietyAngerSuicideSchizophreniaPost-traumatic stressAlcohol abuseOther
Has any family member been treated with a psychiatric medication?*

YesNo
If yes, who in your family was treated, what medications did they take, and how effective was the treatment?
Tobacco History
Have you ever smoked cigarettes?*

YesNo
If yes, how many packs per day?
If yes, how many years?
Family Background and Childhood History
Were you adopted?*

YesNo
Where did you grow up?*
Do you have any siblings?*

YesNo
If yes, list your siblings and their ages.
Did your parents divorce?*

YesNo
Do you have a history of being abused emotionally, sexually, physically or by neglect?*

YesNo
If yes, please describe when, where, and by whom.
Personal History
Highest grade/degree completed?*
Do you have any children?*

YesNo
If yes, please list ages and gender.
Do you exercise regularly?*

YesNo
How many caffeinated beverages do you drink a day?*
Have you ever been arrested?*

YesNo
Do you have any additional information to add?
Telemental Health Consent
Overview*

Telemental health-based services require access to certain services and tools. In order to participate in telemental health services, patients need to give their consent with signatures. Security, benefits, and risks of the service are explained below in detail.
What is Telemental Health?*

Telemental Health is an online therapy service that provides psychological counseling and support to the patients via the internet, video conferencing, phone call and chat.
Benefits and Risks of Telemental Health*

Telemental Health services are using the internet and video conferencing software. Because during appointments, internet technology is used, there may be a disconnection and other difficulties that are the direct result of the low internet speed. Telemental Health services enable patients and specialists to communicate if patients have barriers such as transportation or illness, especially during the pandemic.
Communication Plan*

Desired communication for Telemental Health services is videoconferencing technology. Hence, at first, specialists/therapists try to provide services on videoconferencing software during the appointment date and time. If this is not successful because of the low quality of the video, low internet speed, or any other technical difficulties, specialists/therapists will call patients at the phone number. It is advised to patients to connect 5-10 minutes prior to the appointment time and check whether the internet speed, webcam, and microphone work properly as expected.
Security and Privacy*

The software used in online appointments is protected securely. If patients have concerns about the security and records that will be part of the electronic record system, it is advised that patients let the specialists/therapists know the concerns. Video or audio sessions will not be recorded unless they are discussed and approved for further therapeutic studies and training purposes.
By signing below, I am acknowledging that I have read the above consent and hereby give my consent for James C. Bentley, LCSW to provide psychotherapy to me via telehealth platforms.
Your signature*

Clear
Date*

MonthDayYear
Date
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Personal Information

Medical History

Psychiatric History

Past Psychiatric Medications

Family Psychiatric History

Tobacco History

Family Background and Childhood History

Personal History

Telemental Health Consent