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Patient confirmed identity, date of birth, and state
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Intake Consent
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Presenting Problem
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Patient's Report of ADHD Symptoms:
• • •
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Patient's Report of Other Symptoms:
• • •
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Other
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MEDICAL HISTORY
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Information Was Reviewed
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If No, Explain:
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Update Needed
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If No, Explain:
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Current Medications and Dosage Level
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Estimated Medication Start Date
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Describe Physical Health
• • •
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Personal and Family Medical History
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EMOTIONAL/PSYCHIATRIC HISTORY
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Information Was Reviewed
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If No, Explain:
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Update Needed
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If No, Explain:
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Prior Outpatient Treatment:
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If yes, please describe
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Reason
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Dates treated and by whom
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Prior Inpatient Treatment (for psychiatric, emotional, or substance abuse disorder)
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If yes, please describe
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Reason
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Dates hospitalized and where
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FAMILY HISTORY
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Information Was Reviewed
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If No, Explain:
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Update Needed
|
If No, Explain:
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Mother
• • •
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Father
• • •
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Sister
• • •
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Sister
• • •
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Brother
• • •
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Brother
• • •
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Extended Family (Please specify)
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PAST PSYCHIATRIC MEDICATIONS
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Information Was Reviewed
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If No, Explain:
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Update Needed
|
If No, Explain:
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|
Antidepressants
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Medication name and dosage level
|
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Anxiety Medications
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Medication name and dosage level
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Mood Stabilizers
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Medication name and dosage level
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Sedative/Hypnotics
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Medication name and dosage level
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ADHD Medications
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Medication name and dosage level
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Other Medications (specify)
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SUBSTANCE USE HISTORY
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|
|
Information Was Reviewed
|
If No, Explain:
|
|
Update Needed
|
If No, Explain:
|
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Substance Use Status:
• • •
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Treatment History:
• • •
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Other:
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Substances Used (check all that apply)
• • •
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Other:
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Substances Currently Using
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Suicidality:
• • •
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Suicide Scale
• • •
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Comments on Suicidality
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Homicidality
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Comments on Homicidality
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Abuse Assessment
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Comments about current abuse
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DEVELOPMENTAL HISTORY
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Information Was Reviewed
|
If No, Explain:
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|
Update Needed
|
If No, Explain:
|
|
Problems during mother’s pregnancy
|
If yes, please elaborate
|
|
Any delayed development milestones?
|
If yes, please elaborate
|
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Childhood Health Issues?
|
If yes, please elaborate
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Emotional/Behavioral Problems
|
If yes, please elaborate
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Social Interaction
• • •
|
Intellectual/Academic Functioning
• • •
|
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Highest level of education completed:
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SOCIO-ECONOMIC HISTORY
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|
|
Information Was Reviewed
|
If No, Explain:
|
|
Update Needed
|
If No, Explain:
|
|
Living Situation:
• • •
|
Social Support System:
• • •
|
|
Employment:
• • •
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Financial Situation:
• • •
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Legal History:
• • •
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Military History:
• • •
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Sexual History:
• • •
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Relationship History and Current Family:
• • •
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Religious/Cultural/Ethnic Factors
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Leisure/Self Care
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Goals/Desired Changes
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Objectives
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Interventions
|
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Strengths
|
Barriers
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|
CPT Code:
• • •
|
Suggested Next Therapy Appointment:
• • •
|
|
DSM V
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