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Please fill out the following intake form prior to your first appointment.
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CURRENT PROVIDERS
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Primary Care Physician
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Phone / Fax
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Specialist
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Phone / Fax
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Therapist
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Phone / Fax
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History of Presenting Illness
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What problem(s) are you seeking help for?
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What are your treatment goals?
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Psychiatric Review of Symptoms
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Depression
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Mania
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Anxiety
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Phobias
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Panic
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Obssessive/Compulsive
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Psychosis/Thought
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Trauma
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Attention/Hyperactivity
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Personality
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Feeding and Eating
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Other (please specify):
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Additional Info
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Sleep
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Hours of Sleep Per Night
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Description
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Suicide Risk Assessment
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Have you ever had feelings/thoughts that you didn't want to live?
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Do you currently have feelings/thoughts of suicide?
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If yes, on a scale of 0-10 (ten being the strongest) how strong is your desire to kill yourself currently?
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Do you currently have the means or plan to kill yourself? If yes, please explain.
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Have you ever attempted suicide?
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Additional Info
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PATIENT MEDICAL & PSYCHIATRIC HISTORY
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MEDICATION HISTORY
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Allergies (include medications, food & environmental)
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If yes, please list
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Current Medications (include name, dose, and start date, & reason stopped))
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Are you on hormone replacement therapy (HRT)? If yes, please list.
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Past Psychiatric Medications (include name, dose, start/stop date)
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Additional Info
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PERSONAL MEDICAL HISTORY
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Review of Systems
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General
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Additional Info
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Head, Eyes, Ears, Nose, Throat
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Additional Info
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Cardiovascular
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Additional Info
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Respiratory
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Additional Info
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Gastrointestinal
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Additional Info
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Genitourinary
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Additional Info
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Musculoskeletal
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Additional Info
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Integumentary
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Additional Info
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Neurological
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Additional Info
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Endocrine
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Additional Info
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Hematologic/Lymphatic
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Additional Info
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Allergic/Immunologic
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Additional Info
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Other medical problems/concerns?
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Previous Hospitalizations
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Previous Surgical Procedures
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Most Recent Labs and Tests
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Dental Provider
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Date of Last Dental Service
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Disability Status
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Identify Disability
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Last Menstrual Period (if applicable)
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Are you currently pregnant or think you might be?
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Number of Pregnancies
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Number of Births
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Number of Living Children
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Are you currently on birth control?
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If yes, what kind?
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Additional Info
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PAST PSYCHIATRIC HISTORY
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Past Psychiatric Diagnoses
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Details
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Psychiatric History Includes
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Details
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Previous Psychiatric Hospitalization
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If yes, when and where?
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Hospitalization Status
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Previous Psychiatric Provider(s)
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Additional Info
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SUBSTANCE USE HISTORY
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Substances Used
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Other, please specify
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Substance Use Treatment
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Substance Use Treatment
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Reactions to Treatment Received
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Details
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Additional Info
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FAMILY HISTORY
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FAMILY MEDICAL & PSYCHIATRIC HISTORY
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Family Medical History
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Family Member (include paternal or maternal)
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Family Psychiatric History
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Please list any effective treatments:
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Additional Info
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SOCIAL HISTORY
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Patient's Place of Birth
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Family Biological/Adopted
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If adopted, at what age?
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Number of Moves in Lifetime
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Development
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Details
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Parents
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Other, please specify
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Patient Raised By:
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Has anyone in your immediate family died? If yes, who and when?
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Other Family Information:
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Additional Info
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TRAUMA & ABUSE HISTORY
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Physical
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Details
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Sexual
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Details
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Emotional
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Details
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Neglect
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Details
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Other
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Additional Info
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RELATIONSHIP HISTORY
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Current Relationship Status
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Are you sexually active?
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Describe your relationship with your partner:
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Relationship History
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Children (names and ages)
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Other Information
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Do you feel safe at home?
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If no, please describe:
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Additional Info
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EDUCATION AND WORK HISTORY
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Please describe how you did in school or how you are currently doing:
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Highest level of education completed or current grade?
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Are you currently working?
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If not working, is this by choice?
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Occupation
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Details
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Past Employment
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Additional Info
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LEGAL HISTORY (Explain if Necessary)
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Have you ever been arrested?
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Have you ever been convicted of a crime?
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Current Legal Problems
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Describe:
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Additional Info
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SPIRITUAL HISTORY
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Do you belong to a particular religion or spiritual group?
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Spiritual/Cultural Comments
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Do you feel your involvement is helpful during difficult times, or does it make it more difficult or stressful?
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Is there anything else you'd like me to know?
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Additional Info
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Do you have any barriers to treatment?
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Comments
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Strengths
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Mood Questionnaires
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GAD7
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Problems in the past two weeks:
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Score Values 0-Not at all 1-Several Days 2-More than half the days 3- Nearly everyday
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Feeling nervous, anxious or on edge
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Not being able to stop or control worrying
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Worrying too much about different things
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Trouble relaxing
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Being so restless that it is hard to sit still
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Becoming easily annoyed or irritable
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Feeling afraid as if something awful might happen
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How difficult have these problems made it for you?
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Score
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Representing
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PHQ9 Depression Screen
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Problems in the past two weeks:
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Score Values 0-Not at all 1-Several Days 2- More than half the days 3- Nearly everyday
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Loss of Interest?
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Feeling down, depressed or hopeless?
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Trouble Sleeping, staying asleep or sleeping too much?
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Feeling tired or having little energy?
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Poor appetite or overeating?
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Feeling bad about oneself, like a failure?
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Trouble Concentrating (tv or reading)?
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Feeling slowed down or fidgety & restless that others noticed?
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Wanting to die or self harm?
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Difficulty of these problems?
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Score
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PHQ9 Scoring
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Positive Depression Screen
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Negative Depression Screen
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