x S. Broadway, Suite 7 Pitman, NJ Intake Form
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- Lorin Doyle
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1 Intake Form Name: Date: *If attending couples or family therapy please complete one form for each individual attending treatment. Presenting Problems and Concerns Describe the Problem that brought you here today: Please check all symptoms that are problematic: Distractibility Lack of motivation Hyperactivity Anxiety/worry Impulsivity Panic attacks Boredom Fear away from home Poor memory/confusion Social discomfort Seasonal mood changes Obsessive thoughts Sadness/Depression Compulsive behavior Loss of pleasure/interest Aggression/fights Hopelessness Frequent arguments Thoughts of death Irritability/anger Self-harm behaviors Homicidal thoughts Crying spells Flashbacks Loneliness Hearing voices Low self-worth Visual hallucinations Guilt/shame Suspicion/paranoia Fatigue Racing thoughts Change in appetite Excessive energy Wide mood swings Sleep problems Nightmares Eating problems Gambling problems Computer addiction Issue with pornography Parenting problems Sexual problems Relationship problems Work/school problems Social isolation Alcohol/drug use Recurring disturbing memories Destruction of property Stealing Lying Other: (Child/Adolescents) Defiance Peer/sibling conflict Running away Swearing Curfew violations Manipulative behavior No/few friends Toileting problems Fire setting Legal problems Sexual behavior Are you having problems with any of the following? Handling everyday tasks Self esteem Work/school Housing Recreational activities Sexual activity Relationships Legal matters Health Hygiene Finances Have you ever had thoughts, made statements, or attempted to hurt yourself? Have you ever had thoughts, made statements, or attempted to hurt someone else? Have you recently been physically hurt or threatened by someone else? Have you gambled in the past 6 months? If yes: Have you felt the need to bet more and more money? Have you ever lied to people important to you about how much you gambled?
2 Substance Use History Substance Type Current Use (Last 6 Months) Past Use Y N Frequency Amount Y N Frequency Amount Tobacco Caffeine Alcohol Marijuana Cocaine/Crack Ecstasy Heroin Inhalants Methamphetamines Pain Killers/Opiates PCP/LSD Steroids Tranquilizers Other: Have you had withdrawal symptoms when trying to stop using any substances? Have you had problems with work, relationships, health, the law, etc. due to substance use? Medical Information Date of last physical exam: Have you ever experienced any of the following during your lifetime? Allergies Chronic Pain Dizziness/fainting High fevers Asthma Sexually transmitted diseases Chronic headaches Migraines Concussions/head injury Surgery Meningitis Diabetes Abortion Serious Accident Seizures Hearing problems Vision problems Miscarriage Other: Please list any current health concerns: Current prescription medications: None Medication Dosage Date first prescribed Prescribed by Over the counter medications (including vitamins, herbal remedies, supplements, etc.):
3 Allergies and/or adverse reactions to medication: None If yes, please list: Interpersonal/Social/Cultural Information Please describe your social support network (check all that apply): Family Community group Neighbors Friends Religious/Spiritual Students Co-workers Support/Self-help group How important are spiritual matters to you? Not at all Little Somewhat Very Much Would you like spiritual/religious beliefs incorporated into you counseling? Please describe your religious affiliations if any: If you are experiencing any specific cultural or ethnic issues, please describe: Please describe your strengths, skills, and talents: Describe any special areas of interests or hobbies: Miscellaneous Information Employment: Employer: Length of time in this position: Position: Job Duties: Stress level of this position: Low Medium High Other jobs you have held: Education: Currently attending school? If yes, where/degree: High school graduate? Or GED? Year: Associated Degree: Year: Area of study: Undergraduate Degree: Year: Area of study: Graduate Degree: Year: Area of study: Military Service: Have you been/are currently in the military? (If no, skip section) Branch: Date of Discharge: Type of Discharge: Rank: Were you in combat? If yes: Year(s): Conflict: Legal: Have you ever been convicted of a misdemeanor or felony?
4 If yes, please explain: Are you currently involved in divorce or custody proceedings? If yes, please explain: Previous Mental Health Treatment Yes/No Type of Treatment When? Provider/Program Reason for treatment/outcome Outpatient Counseling Medication (Mental Health) Psychiatric Hospitalization Drug/Alcohol Treatment Self-help/Support Groups Family and Developmental History Please list the individuals who currently live in your household: Name Age Relationship to you Quality of relationship Conflicts Family history of mental health and substance abuse problems: Hyperactivity Sexually Abuse Depression Manic Episodes Suicide Anxiety Panic Attacks Obsessive-Compulsive Anger/Abusive Schizophrenia Eating Disorders Alcohol Abuse Drug Abuse Other Issue Details: (who, timeframe, etc.)
5 Parental Information: Minor/Child Information (Please complete for clients under age 18) Parents legally married or living together Parents temporarily separated Years married/together: Date Separated: Parents divorced or permanently separated Father remarried Number of times Mother remarried Number of times Please check if your child has experienced any of the following types of loss: Emotional abuse Violence in home Neglect Multiple family moves Sexual abuse Teen Pregnancy Crime victim Homelessness Physical abuse Placed a child for Parent illness Loss of a loved one Parent substance abuse adoption Lived in a foster home Financial problems Development Information: Were there any medical problems during the pregnancy or birth of your child? Did the biological mother use any tobacco, medication, street drugs, or alcohol during pregnancy? Did your child have any developmental delays in early childhood (walking, talking, toileting, etc.)? School Information: Current Grade: Current School: This year s school grades: Excellent Good Average Fair Poor Past year s school grades: Excellent Good Average Fair Poor This year s school behavior: Excellent Good Average Fair Poor Past year s school behavior: Excellent Good Average Fair Poor Has your child had any of the following difficulties in school? Suspension Incomplete Learning problems Attendance issues Poor grades homework Speech problems Anxiety Gang influence Teased or picked on Detentions Other: Does your child have a before or after school provider? Has your child ever repeated a grade? Has your child ever received special education services or had an IEP?
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
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
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
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
*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
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
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:
Name Age Relationship to patient
Clackamas Pediatric Clinic Oregon Pediatrics Meridian Park 8645 SE Sunnybrook Blvd #200 19260 SW 65 th Ave #275 Clackamas, OR 97015 Tualatin, OR 97062 (503) 659-1694 (503) 691-2519 Oregon Pediatrics Happy
Child/ Adolescent Questionnaire
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MINOR CLIENT HISTORY
MINOR CLIENT HISTORY CLIENT NAME: DATE: FAMILY & SOCIAL BACKGROUND: Please list and describe your child s or teen s current family members (immediate, extended, adopted, etc.) NAME RELATIONSHIP AGE OCCUPATION
CLIENT HISTORY CLIENT LEGAL NAME: CLIENT PREFERRED NAME:
CLIENT HISTORY CLIENT LEGAL NAME: DATE: CLIENT PREFERRED NAME: FAMILY & SOCIAL BACKGROUND Please list and describe your current family members (immediate, extended, adopted, etc.) and/or other members
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
COUNSELING ASSESSMENT REFERRAL AND BACKGROUND INFORMATION (Adult Form) cell telephones/fax #s/ addresses: (Spouse): (Emergency Contact):
Joanna C. Ioannides, LCSW *Lowry Counseling, LLC *7581 E. Academy Blvd. Ste 209 * Denver, CO 80230*Ph. (720)319-7319 Fax (303)379-4607* counseldenver@aol.com* COUNSELING ASSESSMENT REFERRAL AND BACKGROUND
Client Intake Form. Briefly describe the reason(s) you are seeking psychotherapy at this time:
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
MINDFUL WELLNESS CENTER, PLLC
PATIENT HISTORY NAME DATE PLEASE TAKE YOUR TIME AND COMPLETE THE ENTIRE FORM. You may use the back if needed for more explanation. Identifying Information: Date of Birth: Age: Sex: Place of Birth: Religion:
Sofia P. Simotas, Ph.D., PLLC 2524 Nottingham St. Houston, Texas 77005
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Joan B. Jablow, APMHNP 45 Byram Lake Road Mt. Kisco, New York (914)
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Patient Questionnaire. Name: Date: A. What are the main concerns or problems that brought you here today?
Patient Questionnaire Name: Date: D.O.B.: Age: Referred By: Presenting Problem A. What are the main concerns or problems that brought you here today? B. Problem Checklist: please circle all that apply:
Associates of Behavioral Health Northwest CHILD/ADOLESCENT PSYCHOSOCIAL ASSESSMENT
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*IN10 BIOPSYCHOSOCIAL ASSESSMENT*
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Name: Birthdate: Gender: Address: Phone: (Home) (Work) (Cell) Highest Education Attended: Occupation: Place of Employment:
CLIENT CLIENT INTAKE FORM Client Information Name: Birthdate: Gender: Address: Is it safe to send correspondence to this address, if needed? Yes No Phone: (Home) (Work) (Cell) Is it safe to contact/leave
Address: Spouse/Partner Name: Phone: Address:
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