Northside Mental Health Center Intake Questionnaire

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1 Name: _ Date of Birth: Age: SS# Address: City & State: Zip Code: GOALS How may we help you today? What type of help would you like? Circle all that apply Counseling Medication See a doctor What would you like to achieve in the next few months? What would you like to achieve in the next 2 years? Do you want anyone in your family involved with your treatment? Yes No If yes, who Who referred you to Northside? Hospital Eckerd Mental Health Care Primary Care Doctor State Hospital School Other Emergency Contact: Name & relationship to you Phone 1 Name

2 MENTAL HEALTH AND SUBSTANCE ABUSE TREATMENT HISTORY Where have you been in treatment in the past? Please note if it was outpatient or inpatient, what the treatment was for and when you were there. MEDICAL: ( Biological Section) Do you have any allergies: Yes No If yes, please list: Food: Medication: Environmental: Are you currently taking any over the counter medications? Yes No List: Have you had any operations, medical hospitalizations, or injuries requiring medical care? Yes No If yes, indicate dates and reasons: Are you currently or do you frequently experience any pain that would prevent you from participating in treatment? Yes No If yes, explain: Date of last tuberculosis skin test: Results: Positive Negative 2 Name

3 ADVANCE DIRECTIVES Do you have an Advance Directive? (Someone that you chose to make medical decisions for you if you are unable to, written instructions about your medical care, preferences if you were unable to tell the doctor yourself) Yes No Do you want information about Advance Directives? Yes No Do you have a Psychiatric Advance Directive? (Someone that you chose to make decisions about your mental health care if you are unable to make those decisions, yourself, written instructions about your preferences if you were unable to tell your doctor yourself) Yes No If yes can we have a copy? Yes No Is there anyone you would like us to contact if you needed a higher level of care? Yes No If yes, who If you needed a higher level of care (like a crisis stabilization hospital/ unit) is there a specific place that you would prefer to go? Yes No Where Do you want information about psychiatric advance directives? Yes No GENDER IDENTITY AND SEXUAL FUNCTIONING What gender are you? Male Female Other Do you have any concerns about your gender? (For example, being a man but feeling like you are a woman.) : Yes No If yes, please explain: What is your sexual orientation? (Who are you sexually attracted to?) heterosexual (attracted to opposite sex) homosexual (attracted to same sex) bisexual (attracted to males and females) asexual (no sexual attraction to anyone) Do you have any concerns related to sex or relationships? 3 Name

4 NUTRITIONAL/EATING Weight Loss/ or weight gain of 10 pounds or more in the past six months without trying Yes No Have you ever been below the normal weight for your age and height on purpose? Yes No Do you have a big fear about gaining weight or becoming fat? Yes No Have you ever binged, purged or used laxatives for weight loss? (Excessive eating, made yourself vomit) Yes No Do you feel out of control with your eating? Yes No Do you want information about healthy eating? Yes No GAMBLING Have you ever gambled? Yes No If yes, has gambling caused financial problems for you or your family? Yes No If yes, please explain: MEDICAL HISTORY CHECKLIST: (Check off past or current diagnosis or problem) Never Current Past Asthma Diabetes Head injury Hearing Problem Heart disease Hepatitis A, B, or C High Blood Pressure HIV/AIDS Lost consciousness Motor Skills Problem Seizures 4 Name

5 Other: Do you have a medical doctor? Yes No Name of your Primary Care Doctor Phone# Date last seen by your doctor: Does your medical doctor know about the problems you checked? Yes No Are you currently receiving treatment for any medical problems? Date of last Dental Exam: List any other doctors you are currently seeing and why: FINANCIAL STATUS Please estimate the current, monthly family gross income: Indicate the source(s) of household income within the last 30 days and indicate amount received: Paid Work SSI SSDI TANF/AFDC/WAGES Child Support Unemployment Compensation SSD Other: EDUCATIONAL Can you read? Yes No What is the highest level of education you have completed: Tech/Trade school (subject): Are you currently enrolled in school? Yes No If yes, which school? Do you want referral information for help with educational needs? Yes No If yes, what needs? 5 Name

6 EMPLOYMENT Are you currently employed? Yes Full time Part time No If yes, how long have you been at your current job? Type of work: What is the longest period of time you have held the same job? What is your usual occupation? What plans or goals do you have regarding work? MILITARY Have you ever served in the military? Yes No If yes, for how long? Discharge type? (Please circle one) Honorable Dishonorable Disabled Service related concerns: LEGAL Have you ever been arrested? Yes No If yes, please list below: Year Charge Sentence 6 Name

7 Currently, are you on Start date Length Parole Probation House Arrest Electronic Monitoring Charges Pending Who is your probation/parole officer? Name & phone number Does your name appear on the Sex Offender Registry? Yes No Do you have a legal situation that may interfere with treatment or that you need help with? Yes No If yes, what needs? CHILD WELFARE Has child protective investigation come to your home or has your child been removed from your care by the authorities? Yes No If yes, is there an open case? Yes No If yes, who is the caseworker? Is there a guardian Ad Litem? Yes No If yes, who CULTURAL Please select which best describes your cultural background: Islander European African American Indian Hawaiian/Pacific Puerto Rican Mexican Cuban Haitian Asian White Black Middle Eastern Caribbean Latino East Indian 7 Name

8 What is the language you speak most often? List any cultural value, belief, or practice that should be considered in your services from Northside Mental Health Center: RELIGIOUS/SPIRITUAL ORIENTATION Are you active in a religious or spiritual practice? Yes No If yes, what religion? List any religious/spiritual beliefs that should be considered in your services from Northside Mental Health Center: RECREATIONAL/ LEISURE INTERESTS (i.e. photography, cards, baseball or reading of your child if parent is completing) How do you spend your days? Please list any activity you enjoy and check how much time you spend on each one: Activity/ Interests Frequency (once a week, once a month, daily) 8 Name

9 COMMUNITY RESOURCES/ SOCIAL ACTIVITIES- Do you use any of the following: Public transportation Yes No Church/Temple Yes No Social Groups Yes No Home Health Care Yes No Support Groups Yes No 12 Step Groups/ AA, NA, Yes No Sports Yes No Organizations Yes No Other community resources Yes No FAMILY Current Living Situation Homeless Stable Unstable/concerns: SIGNIGICANT RELATIONSHIPS First Name of partner Length of relationship Reason Ended Number of living children Number of deceased children Who in your life is supportive? 9 Name

10 SELF - CARE Do you have any difficulty taking care of yourself: Yes No, if yes please describe: Client Signature I have completed this to the best of my ability Date Intake Staff Therapist Date Date 10 Name

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