• Mental Health Intake Form
    Therapeutic Medical and Psychiatric Services

    Please complete all information on this form and bring it to the first visit. It may seem long, but most of the questions require only a check, so it will go quickly. You may need to ask family members about the family history. Thank you!

  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Date of BIrth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • May we send your info to your primary care provider?
  • Are you married?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • May we contact your spouse/partner with information about you?
  • Format: (000) 000-0000.
  • Date problems started:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Have you ever been treated for this before?
  • Current Symptoms Checklist: (check once for any symptoms present, twice for major symptoms)
    Rows

  • Suicide Risk Assessment

  • Have you ever had feelings or thoughts that you didn't want to live?

  • If YES, please answer the following.

    If NO, please skip to the next section.

  • Do you CURRENTLY feel that you don't want to live?

  • Past Medical History

  • List ALL current prescription medications and how often you take them: (if none, write none)
  • Have you ever had an EKG?
  • Was the EKG

  • FOR WOMEN ONLY

  • Date of last menstrual period
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you currently pregnant or do you think youmight be pregnant?
  • Are you planning to get pregnant in the near future?
  • Are you on hormone replacements?
  • Have you had a hysterectomy?
  • Total abdominal?
  • Do you have any concerns about your physical health that you would like to discuss with us?
  • Date of last physical exam:
     / /
    2 digit month, 2 digit day, 4 digit year

  • Personal and Family Medical History

  • Type a question
    Rows
  • Is there any additional personal or family medical history?

  • Past Psychiatric History:

  • Have you ever had outpatient treatment?
  • If yes, Please describe when, by whom, and nature of treatment.
    Rows
  • Have you ever had psychiatric hospitalization?
  • If yes, please describe for what reason, when and where.
    Rows

  • Past Psychiatric Medications: If you have ever taken any of the following medications, please indicate the dates, dosage, and how helpful they were (if you can't remember all the details, just type what you do remember).

  • Antidepressants
    Rows
  • Mood Stabilizers
    Rows
  • Antipsychotics/Mood Stabilizers
    Rows
  • Sedative/Hypnotics
    Rows
  • ADHD medications
    Rows
  • Antianxiety medications
    Rows

  • Therapy/Counseling History:

  • Have you ever had therapy before?
  • Are you currently in therapy at present?
  • Would you be interested in therapy?

  • Your Exercise Level:

  • Do you exercise regularly?

  • Family Psychiatric History:

  • Has anyone in your family been diagnosed with or treated for:
    Rows
  • Has any family member been treated with a psychiatric medication?

  • Substance Use:

  • Have you ever been treated for alcohol or drug use or abuse?
  • Have you ever felt you ought to cut down on your drinking or drug use?
  • Have people annoyed you by criticizing your drinking or drug use?
  • Have you ever felt bad or guilty about your drinking or drug use?
  • Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?
  • Do you think you may have a problem with alcohol or drug use?
  • Have you used any street drugs in the past 3 months?
  • Have you ever abused prescription medication?
  • Check if you have ever tried the following:
    Rows
  • How many caffeinated beverages do you drink a day?
    Rows

  • Tobacco History:

  • Have you ever smoked cigarettes?
  • Are you currently smoking cigarettes?
  • Did you smoke cigarettes in the past?
  • Do you currently use the following:
    Rows

  • Family Background and Childhood History:

  • Where you adopted?
  • Did your parents' divorce?

  • Trauma History:

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

  • Educational History:

  • Occupational History:

  • Are you currently:
  • Honorable discharge

  • Relationship History and Current Family:

  • Are you currently:
  • If not married, are you currently in a relationship?
  • Are you sexually active?
  • How would you identify your sexual orientation?
  • Have you had any prior marriages?
  • Do you have children?

  • Legal History:

  • Have you ever been arrested?

  • Spiritual Life:

  • Do you belong to a particular religion or spiritual group?
  • Do you find your involvement helpful during this illness, or does the involvement make things more difficult or stressful for you?
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • For Office Use Only:

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: