2550 Middle Road, Suite 316 Bettendorf, Iowa Adult Intake Form
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- Janel James
- 5 years ago
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1 Adult Intake Form 2550 Middle Road, Suite 316 Bettendorf, Iowa Thank you for choosing Quad City Women s Therapy. I collect the following information help me have a comprehensive understanding of your biological, psychological, social, and spiritual history and present condition. I understand this is a LOT of information. If there are questions that make you uncomfortable or you prefer not to answer, you can leave those blank. Thank you for your time in completing this form. Basic Information Name (First, Middle, Last): Date of Birth: Age: Gender: Race: Ethnicity: Street Address: City: State: Zip: Primary Phone: Secondary Phone: Emergency Contact(EC): Relationship: EC Phone: EC Presenting Problems and Concerns: What brought you here today? Please check all the behaviors and symptoms you consider problematic: Relationship w/ partner Withdrawal from people Increased risky behavior Relationship w/ child(ren) Sadness/Depressed Loss of enjoyment Trouble Sleeping/Nightmares Concentration/Forgetful Decrease/Increase Libido Wide Mood Swings Self-harming Anger/Irritability Unmotivated Impulsive/Compulsive Pornography Social discomfort Thoughts of death Computer addiction Anxiety/Worry Panic Attacks Low self-worth Avoidance Suspicion/Paranoia Flashbacks Obsessive thoughts Hyperactivity Seeing/Hearing things Guilt/Shame Alcohol/Drug use Racing thoughts Hopelessness Fatigue/tired Change in appetite Gambling problems Other: Other: Are these behaviors and symptoms affecting any of the following? Handling everyday tasks Self-esteem Health/Hygiene Relationships Sexual Activity Work/School Housing/Finances Legal Maters Parenting Hobbies/Recreation Other: Other: 1
2 Medical Information & History Primary Care Physician: Psychiatrist: Date of last physical exam: Phone: Phone: Health Status: Excellent q Good q Fair q Poor q Do you personally have now or have you had in the past any of the following? Personal Health History Age of Details (tell me about your condition) Onset Heart disease? Yes q No q Respiratory illness? Yes q No q Neurological Issues? Yes q No q Lung disease? Yes q No q Endocrine disease (diabetes)? Yes q No q Cancer? Yes q No q Liver/Pancreas/Kidney disease? Yes q No q Gastrointestinal illness? Yes q No q Skin/Circulatory issues? Yes q No q Blood/bone disease? Yes q No q Reproductive (genitourinary)? Yes q No q Anything else you think is important? Yes q No q If yes, please describe Were you vaccinated as a child? Yes q No q Does your mother, father, grandparent, sibling or child have now or have a history of the following? Family Mental Health History Family Details (tell me about their condition) Member ADHD? Yes q No q Depression? Yes q No q Anxiety? Yes q No q PMS or PMDD? Yes q No q Bipolar disorder? Yes q No q Suicide attempt/self-harm Yes q No q Addiction? Yes q No q Sexual Abuse? Yes q No q Obsessive Compulsive Disorder? Yes q No q Schizophrenia? Yes q No q Psychosis? Yes q No q Postpartum Issues? Yes q No q Anything else you think is important? Yes q No q If yes, please describe Please list any/all allergies and reactions. Allergy Reaction 2
3 Please list all medications or drugs you take or have taken in the last year (prescribed, over-the-counter, other). Medication/Drug Dose Taken for Prescribed/Supervised by Reproductive/Maternal History How old were you when you started menstruation? Do you experience mood changes around the time of your period? Yes q No q If yes, are those mood changes: Mild q Moderate q Severe q Do you use a method of birth control now? Yes q No q if yes, what? Have you used birth control in the past? Yes q No q if yes, what? Are you satisfied with your sexual functioning (enjoyment of sexual intercourse)? Yes q No q Has there been any change in your sexual desire or frequency of sex in the past 6 months? Yes q No q How many times have you been pregnant? How many living children do you have? Have you had difficulty getting pregnant? Yes q No q Have you had infertility treatment? Yes q No q Have you ever experienced distress/pain/challenges with breastfeeding? Yes q No q Pregnancy History: Please list all pregnancies and any issues you experienced. Year Delivery Date Gestational Age Any Issues/Problems with pregnancy/delivery? Mental Health History Have you received mental health treatment previously? Yes q No q Have you ever been diagnosed with a mental health condition like Depression, Anxiety, OCD, etc.? Yes q No q Treatment Type When Provider/Program Reason for Treatment Outpatient Counseling Psychiatric (Medication) Psychiatric Hospitalization Drug/Alcohol Treatment Self-help/Support Group Have you ever had thoughts that you didn t want to live? Yes q No q Have you ever had thoughts of harming yourself? Yes q No q 3
4 Have you ever tried to kill or harm yourself before? Yes q No q Have you been hearing or seeing things that other people do not hear or see? Yes q No q If yes, please describe: Have you recently been physically hurt or threatened by someone else? Yes q No q Have you ever had thoughts, made statements, or attempted to seriously hurt or kill someone else? Yes q No q If you delivered a baby recently, have you had thoughts of harming your baby? Yes q No q If yes, please describe: If yes, were those thoughts (check all that apply): Unwanted q Intrusive q Disturbing q Logical q Right q Trauma History Have you ever experienced any of the following types of trauma or loss? Emotional abuse Sexual abuse/assault Physical abuse Parent substance abuse Parental divorce Neglect Violence in the home Crime victim Parent illness/mental illness Placed a child in adoption Lived in a foster home Multiple family moves Homelessness Loss of a loved one Financial problems Miscarriage/Stillborn Parent in jail/prison Other: Substance Use History Have you ever felt you needed to cut down or stop a substance or an activity? Yes q No q If yes, please describe: Have other people told you that you need to cut down or stop a substance or an activity? Yes q No q Have you ever felt unable to cut down or stop a substance or an activity? Yes q No q Has your use or a compulsive activity caused any problems in your relationships, with work or school, with your health or with the law? Yes q No q Please mark you current use of the substances below. Substance Current Use? How Much? How Often? Past Use? Example: Coffee Yes 2 cups Daily Yes Caffeine Alcohol Tobacco Marijuana Cocaine Heroin Pain Killers Inhalants Methamphetamines Ecstasy 4
5 Substance Current Use? How Much? How Often? Past Use? PCP/LSD Steroids Tranquilizers Hallucinogens Other: Relationships/Social History Are you? Married q Single q Widowed q Divorced q In a Relationship q How long? Any previous relationships to note? How long? What is your sexual orientation? Please list everyone who lives in the home with you and the quality of your relationship. Person s Name Age Relationship to you Quality (poor, fair, good, excellent) Example: John 4 Son Good but I feel like I yell at him daily Who did you live with growing up? List the people in your home for most of your childhood. How would you rate the quality of your relationships with your family of origin (parents, siblings, grandparents, etc.)? Excellent q Good q Fair q Poor q Is there anything important I should know about your childhood/growing up?: Please mark any of the following you consider social supports. Family Neighbors Support/Self-help group Friends/Students Co-workers Religious/Spiritual Center Community Group Other Do you work outside the home? Yes q No q If yes, what is your occupation? Have you served in the military? Yes q No q If yes, when and what rank? Describe, in your own words, how you spend most of your time: Describe, in your own words, what you do in your free time? Do you belong to a cultural or religious group? Yes q No q If yes, what? Do you have religious or spiritual beliefs? Yes q No q If yes, what? 5
6 How important is your faith/religion/spirituality to you? Very q Somewhat q Neutral q Sort of q Not at All q Please describe your skills/strengths/talents? What was/is the most difficult time of your life and why? What was/is the best time of your life and why? What has worked for you in the past to get through a difficult time? Do you have any special interests/hobbies? Yes q No q If yes, what? Have you ever or are you currently facing legal charges/difficulties? Yes q No q Please use this space to tell me anything you think it is important that I know to better serve you: Please write down, in your own words, 3 goals you have for therapy: You have now reached the end of the intake form. Thank you for your time. We will review this information at your first session. If there is anything you do not feel comfortable discussing, please let me know. Please sign and date below. Signature: Date: 6
CLIENT INFORMATION FORM. Name: Date: Address: Gender: City: State: Zip: Date of Birth: Social Security Number:
Name: Address: Gender: City: State: Zip: Date of Birth: Social Security Number: Contact Telephone Numbers Please complete relevant information and indicate the number at which you wish to be contacted
Demographic Information Form
PATIENT INFORMATION Demographic Information Form / / Mailing: Male Female SSN#: - - Home Cell Relationship Status (circle one): Single / Married / Divorced / Widowed / Other: ( ) - ( ) - (Preferred Phone
Demographic Information Form
Demographic Information Form PATIENT INFORMATION Male Female Other / / (Patient Legal Last Name) (Patient Legal First Name) (MI) (DOB) Mailing: SSN#: - - Home Cell Relationship Status (circle one): Single
Intake Form. Presenting Problems and Concerns. When did it start and how does it affect you:
Intake Form Name: Date: Presenting Problems and Concerns Describe the problem that brought you here today: When did it start and how does it affect you: Estimate the severity of the above problem: Mild
x S. Broadway, Suite 7 Pitman, NJ Intake Form
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Please check all the behaviors and symptoms that you consider problematic:
Name Date Address Phone # Date of birth Email address Social Security Describe the issue that brought you here today: Please check all the behaviors and symptoms that you consider problematic: Distractibility
*Please complete this form and bring to your first appointment. This information is fundamental to the assessment and treatment process.
*Please complete this form and bring to your first appointment. This information is fundamental to the assessment and treatment process. PATIENT CONTACT INFORMATION Name Age Date of birth Phone ( ) Mailing
Adult Intake Form. Name: Date: Describe the problem that brought you here today: Briefly share relevant history behind this problem:
Adult Intake Form Date: Describe the problem that brought you here today: Briefly share relevant history behind this problem: Check any of the following symptoms that you are experiencing: Distractibility
Child and Youth Background Information
Child and Youth Background Information CHILD S NAME: SUBSTANCE USE HISTORY (for ages 12 and older or if applicable) Substance Type Current Use (last 6 months) Past Use: Please check and complete all that
507 N Davis Drive Suite 1A Warner Robins, GA Phone: (478) Fax: (478)
Office Use Only Client # Ins. Dx: Need Monthly Statement? Yes No EAP Yes No Individual Family Today s Date: GENERAL INFORMATION Please print Client Name: Last First: MI: Mailing Address: City: State: Zip:
Adult Information Form Page 1
Adult Information Form Page 1 Client Name: Age: DOB: Date: Address: City: State: Zip: Home Phone: ( ) OK to leave message? Yes No Work Phone: ( ) OK to leave message? Yes No Current Employer (or school
Adult Information Form
1 Client Name: Age: DOB: Today s Date Address: City: State: Zip: Home Phone: ( ) Ok to leave message? YES NO Work Phone: ( ) Ok to leave message? YES NO Current Employer (or school if a student): Gender:
PSYCHIATRIC INTAKE AND TREATMENT PLAN-PART I TO BE FILLED BY PATIENT PLEASE PRINT
DOB: / / / PSYCHIATRIC INTAKE AND TREATMENT PLAN-PART I TO BE FILLED BY PATIENT PLEASE PRINT Date Age Gender M F Current address: Married. Single Separated Divorced Widowed If patient is a child, he/she
CLIENT HISTORY CLIENT LEGAL NAME: CLIENT PREFERRED NAME:
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Client Intake Form Thank you for taking the time to openly and honestly answer the questions below. Your genuine responses are appreciated, as all information provided will assist your therapist to better
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Becky Nickol, NCC, LMHC Licensed Mental Health Counselor, MH 8569 240 Wood Lake Drive Maitland, Florida 32751 407-831-7783 becky@beckynickol.com Adult Biopsychosocial Assessment General Information Date:
New Client Questionnaire: (rev. 08/2016)
New Client Questionnaire: (rev. 08/2016) Client Name: Date of Birth: / / Date of First Session: / / What events or concerns brought you to my office? What goals would you like to accomplish? Are there
Psychiatric Evaluation Intake Form
Patient Contact Information Psychiatric Evaluation Intake Form Patient Name: Date of Birth: Age: Last First MI Address: Contact phone number: Email address: Emergency Contact/Number/Relationship: Primary
Client Intake Form. First Name: M.I.: Last Name: Birthdate: Gender: Age: Address: City: State: Zip:
Client Intake Form First Name: M.I.: Last Name: Birthdate: Gender: Age: Address: City: State: Zip: Tel: Home: Okay to leave message? (Circle one) Yes No Tel: Work: Ext Okay to leave message? (Circle one)
Crawford consulting and mental health services, inc ADULT PSYCHOSOCIAL ASSESSMENT
ADULT PSYCHOSOCIAL ASSESSMENT The following necessary information will help make your first session most productive, Signed consent is required from the parent(s) or legal guardian before treatment can
Center for Transformative Counseling, Inc. 801 Georgia Street Key West, FL
Center for Transformative Counseling, Inc. 801 Georgia Street Key West, FL 33040 305-407-7676 Identifying Information Counseling Intake Name Nickname/Name you want to be called Address Phone Numbers (home,
ADULT INTAKE QUESTIONNAIRE. Ok to leave message? Yes No. Present psychological difficulties please check any that apply to you at this time.
ADULT INTAKE QUESTIONNAIRE Name: Today s Date: Age: Date of Birth: Address: Home phone: Work phone: Cell phone: Ok to leave message? Yes No Ok to leave message? Yes No Ok to leave message? Yes No Email:
New Patient Questionnaire
New Patient Questionnaire Date of appointment (MM/DD/YYY): Name (Last, First, MI): Previous Names: DOB (MM/DD/YYY): Phone: Cell: Email: May we email you with sensitive information, such as test results?
LEXIE SMITH LPC 116 W. 7th, Suite 211 Stillwater, OK Date. Personal History Information
1 LEXIE SMITH LPC 116 W. 7th, Suite 211 Stillwater, OK 74074 405-707-9600 Date Personal History Information Client's Name Referred By Address Phone City/State/Zip Birthdate Age Occupation Employed by Social
C O U P L E S I N T A K E F O R M
COUPLE S INTAKE FORM CONFIDENTIAL Name Today s Date Contact information: Address: City: State: Zip: Phone number (cell): (home): (work): Email address: Date of Birth May I leave a voicemail on your cell
Driftwood Psychological Services 664 Scranton Rd., Suite 201 Brunswick, GA Phone:
1 Driftwood Psychological Services 664 Scranton Rd., Suite 201 Brunswick, GA 31525 Phone: 912-230-2436 drtara@driftwoodpsych.com Client name Date ADULT HISTORY FORM Presenting problems Why I came for counseling:
ADULT INITIAL EVALUATION: Patient Form
ADULT INITIAL EVALUATION: Patient Form Date: Patient: DOB: Referred by: Name of Person completing this form if not patient: Briefly describe the events that led to this appointment. Have there been any
PHARMACY INFORMATION:
Patient Name: Date of Birth: Referred by: Reason for Visit: Current psychiatric medications and doses: PHARMACY INFORMATION: Name of Pharmacy: Phone Number: Fax Number: Address: PRIMARY CARE PHYSICIAN
CONFIDENTIAL. Name Today s Date. Address: City: State: Zip: Phone number (cell): (home): (work): address: Emergency Contact (name): (number):
INTAKE FORM CONFIDENTIAL Name Today s Date Contact information: Date of birth Address: City: State: Zip: Phone number (cell): (home): (work): Email address: May I leave a voicemail on your cell or home
Intake Information Form
Intake Information Form First Name: MI: Last : Birth date: / / Referred by: Insurance / other: Address: City:, Zip: living with: phone: (H): (W): (C): Email: Occupation: FT / PT since: Student: yes / no
Heartland Wellness Counseling Health Questionnaire
Heartland Wellness Counseling Health Questionnaire Today s Date: CLIENT INFORMATION Last name: First: Middle: Initial: Nick name: Marital status: Single Married Divorced Separated Widow Social Security
BETHESDA WORKSHOPS: HEALING FOR MEN PARTICIPANT INFORMATION FORM
BETHESDA WORKSHOPS: HEALING FOR MEN PARTICIPANT INFORMATION FORM Name Age Preferred first name Address City, State Zip Phone (Day) -_- Cell --_ Email address Occupation (indicate former occupation if retired)
Name Last First Middle Date. Completed by: If not client, relationship to client. Reason for Seeking Counseling:
CLIENT HISTORY (PSYCHOLOGICAL, SOCIAL, PHYSICAL and SPIRITUAL) Name Last First Middle Date Completed by: If not client, relationship to client Reason for Seeking Counseling: Personal Information Sex: [
Mental Health Intake Form
Current Symptoms Checklist: (check once for any symptoms present, twice for major symptoms) ( ) ( ) Depressed mood ( ) ( ) Racing thoughts ( ) ( ) Excessive worry ( ) ( ) Unable to enjoy activities ( )