ELEMENTAL CENTER MENTAL HEALTH INTAKE FORM

Transcription

1 1 Please complete all information on this form. It may seem long, but most of the questions require only a check, so it will go quickly. Thank You! Personal Information First Name Last Name Gender DOB Address City State ZIP Code Referral Source Emergency Contact Information Phone OK to leave a message? Alternate Phone # Yes No First Name Last Name Gender DOB Address City State ZIP Code Relationship Phone Alternate Phone What are your problems for which you are seeking help? Mental Health Providers Current Psychiatrist: Phone# Current Therapist/Counselor: Phone # Page 1 of 10

2 2 Have you ever been admitted as an Inpatient to a Mental Health Hospital? Yes No If Yes, What Year(s)? What was the reason? Have you ever completed a Partial Hospitalization Program (PHP) Yes No If Yes, What Year? Where? Have you ever completed an Intensive Outpatient Program (IOP) Yes No If Yes, What Year (s)? Where? Current Symptoms: Depressed Mood Increased libido Binge Eating Unable to Enjoy Activities Decrease need for sleep Anorexia Sleep pattern disturbance Excessive energy Alcohol Use Loss of Interest Increased irritability Marijuana Use Concentration/Forgetfulness Crying spells Opiates Use Change in Appetite Excessive worry Cocaine Use Excessive Guilt Panic attacks Sedatives Use Fatigue Avoidance Stimulants Use Decreased libido Hallucinations Hallucinogens Use Racing thoughts Paranoia Methamphetamines Impulsivity Self-injury Other: Increased Risky Behavior Bulimia Suicide Risk Assessment: Have you ever had thoughts that you did not want to live? Yes No If yes, answer the following. If No, please skip to the Harm towards Others Section Do you currently feel that you do not want to live? Yes No On a scale 1 10, 10 being the strongest, how strong is your desire to kill yourself? How often do you have these thoughts? When was the last time you had thought of dying? Has anything happened recently to make you feel this way? Have you ever thought how you would kill yourself? What is the method you would use to kill yourself? Have you planned a time for this? Yes No Is there anything that would stop you from killing yourself? Have you ever tried to kill or harm yourself before? Yes No When and how Do you have an access to a gun? Yes No Page 2 of 10

3 3 Harm towards Others/Property Assessment: Have you ever had thoughts that you want to hurt other people? Yes No If yes, how often do you have these thoughts? Have you recently harmed another person? Yes No If yes, who is the person? Describe last attempt to harm another person: Have you ever destroyed property? If yes, describe last destructive behavior towards property: Medications: Antidepressants Prozac Zoloft Luvox Paxil Celexa Lexapro Effexor Cymbalta Wellbutrin Remeron Serzone Anafranil Pamerol Tofranil Elavil Other: Medications: Mood Stabilizers Tegretol Lithium Depakote Lamictal Tegretol Topamax Page 3 of 10

4 4 Other: Medications: Antipsychotic/Mood Stabilizers Seroquel Zyprexa Geodon Abilify Clozaril Haldol Prolixin Risperdal Other Medications: Sedatives/Hypnotics Ambien Sonata Rozerem Restoril Desyrel Other Medications: ADHD Medications Adderral Concerta Ritalin Straterra Other Medications: Antianxiety Xanax Ativan Page 4 of 10

5 5 Klonopin Valium Klonopin Valium Tranxene Buspar Other Trauma History Has anyone in your immediate family died? Yes No If Yes, who and when? Do you have a history of being abused verbally Yes No Physically Yes No Sexually Yes No Describe when, where and by whom? _ Family Psychiatric History Has anyone in your family been diagnosed or treated with: Bipolar Disorder Yes No Schizophrenia Yes No Depression Yes No PTSD Yes No Anxiety Yes No Alcohol Abuse Yes No Anger Yes No Other Substance Use Yes No Suicide Yes No Violence Yes No If yes, who and for which mental illness: Has anyone in your family been treated with psychiatric medications: Yes No If yes, who and which medications? Substance Use Assessment Have you ever been treated for Alcohol and/or Drug use and/or abuse? Yes No If yes, for which substances? Where have you been treated and when? How many days per week do you drink any alcohol? What is the least number of drinks you would drink in a day? What is the most number of drinks you would drink in a day? In the past 3 days what is the largest amount of alcohol you consumed in one day? Have you ever felt you need to cut down on your drinking or drug use? Yes No Have you ever felt guilty about your alcohol and drug use? Yes No Page 5 of 10

6 6 Have you ever had a drink or used drugs the first thing in the morning to steady your nerves? Yes No Do you think you have a problem with alcohol or drug use? Yes No In the past 3 months have you used any street drugs? Yes No If yes, which ones? Have you ever abused prescription medications? Yes No If yes, which ones and for how long? Check if you have ever tried the following: If Yes, how long and when did you last use? Alcohol Yes No Cocaine Yes No Stimulants pills Yes No Heroin Yes No LSD or Hallucinogens Yes No Marijuana Yes No Pain killers Yes No Methadone Yes No Tranquilizer/sleeping pills Yes No Ecstasy Yes No Methamphetamine Yes No Other: Tobacco Use Assessment Do you currently smoke cigarettes? Yes No If yes, how many packs per day do you smoke? How many years? Have you smoked in the past? Yes No How many years did you smoke? When did you quit? Do you smoke E-cigarettes? Yes No Do you currently smoke a pipe? Yes No Chew tobacco? Yes No Smoke cigars? Yes No Medical History Primary Care Physician: Phone # Allergies: Current Weight Height Page 6 of 10

7 7 List all prescription medications and how often do you take them: Medication Total Daily Dosage Estimated Start Date Current over the counter medications: Current medical problems: Past medical problems, non-psychiatric hospitalizations, surgeries: Have you ever had an EKG? Yes No If yes, when Was the EKG Normal Abnormal or Unknown For women only: Date of last menstrual period: Are you currently pregnant? Yes No Birth control method How many times have you been pregnant? How many live births? Date of last physical exam Have you been discharged from a medical facility within 30 days? Yes No If yes, please list the facility and the reason: Do you have any concerns about your physical health that you would like to discuss with me? Yes No Would you like to schedule an appointment for a holistic nutritional analysis with chiropractic therapy? Yes No Personal and Family History Allergies Anemia Asthma/Respiratory Problems Cancer Diabetes Chronic fatigue Chronic pain Epilepsy or seizures Head Trauma High Cholesterol High Blood Pressure HIV/AIDS Heart Disease You Family Which Family Member Page 7 of 10

8 8 Fibromyalgia Kidney Disease Liver Disease Stomach or Intestinal problems Stroke Thyroid Disease Is there any additional personal/family history? Yes No. If yes, please explain: When your mother was pregnant with you, were there any complications during the pregnancy or birth? Yes No Current signs of Withdrawal Nausea Vomiting Sweats Tremors Seizures Depression Sleep issues Delirium tremens Fever Anxiety Agitation Hallucinations Exercise Level Do you exercise regularly? Yes No How many days a week do you exercise? How much time each day do you exercise? What kind of exercise do you do? Family Background and Family History Where did you grow up? Were you adopted? Yes No List your siblings and their ages: List your parents and their ages: Where your parents divorced? Yes If yes, how old where you when they divorce? If your parents were divorced who did you live with after the divorce? How was your relationship with your Mom? How was your relationship with your Father? What was your Mom s occupation? What was your dad s occupation How old where you when you left home? Educational History Did you graduate from High School? Yes No Did you graduate from College? Yes No What is your highest educational level or degree attained? Occupational History Please check your status Working full-time Working part--time Student Disabled Retired Unemployed Page 8 of 10

9 9 How long in present position? What is your occupation? Where do you work? Have you ever served in the military? If yes, what branch? When? Honorable discharge? If no, what kind of discharge? Relationship History and Current Family Please check your status: Married Partnered Divorced Single Widowed How long? If not married, are you currently in a relationship? How long Are you sexually active? Yes No How would you identify your sexual orientation? Heterosexual Lesbian/gay/homosexual Bisexual Transsexual Unsure/questioning Asexual Other Prefer not to answer How is your relationship with your partner? Have you had any previous marriages? If yes, how many? How long? Do you have any children? If yes, list ages and gender: How is your relationship with your children? List everyone who currently lives with you: Legal History Have you ever been arrested? Yes No Do you have any pending legal matters? Yes No Which County Are you required by Court to receive counseling? Yes No Spiritual Life Do you belong to a particular religion or spiritual group? Yes No If yes, what is the level of your involvement? Have you ever attended 12 step meetings? Yes No Goals Please list your goals: Page 9 of 10

10 10 Additional Comments Signature Date: Guardian Signature (if under age 18) Date: For office use only Reviewed by: Name of Provider Signature of Provider Date Page 10 of 10