Mental Health Intake Form
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1 38600 Van Dyke Ave., Suite 200 Sterling Heights, MI Phone: (586) Fax: (586) Mental Health Intake Form 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! Name: Date: / / Address: Date of Birth: / / Age: Phone Number: ( ) - Primary Care Physician: Phone Number: ( ) - Do you give permission for ongoing regular updates to be provided to your primary care physician? Yes or No Therapist/Counselor You Are Seeing: Emergency Contact: Phone Number: ( ) - What are the problem(s) for which you are seeking help? Current Symptoms Checklist: Depressed mood Racing thoughts Excessive worry Excessive guilt Increased irritability Unable to enjoy activities Impulsivity Anxiety Attacks Crying spells Increased libido Decreased libido Sleep pattern disturbance Increase risky behavior Avoidance Hallucinations Excessive energy Change in appetite Fatigue Decrease need for sleep Loss of interest Concentration/forgetfulness Suicide Risk Assessment Have you ever had feelings or thoughts that you didn't want to live? Yes or No 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? Yes or No How often do you have these thoughts? When was the last time you had thoughts of dying?
2 Has anything happened recently to make you feel this way? On a scale of 1 to 10, (ten being strongest) how strong is your desire to kill yourself currently? Would anything make it better? Have you ever thought about how you would kill yourself? Is there anything that would stop you from killing yourself? Do you feel hopeless and/or worthless? Have you ever tried to kill or harm yourself before? Do you have access to guns? If yes, please explain. Identification: Ethnicity: (optional) Do you belong to a particular religion or spiritual group? Yes or No Do you find your religious affiliation helpful during this time, or does the involvement make things more difficult or stressful for you? More helpful Stressful Are you currently: Married Partnered Divorced Single Widowed How long? If not married, are you currently in a relationship? Yes No If yes, how long? Are you sexually active? Yes or No How would you identify your sexual orientation? straight/heterosexual lesbian/gay/homosexual bisexual transsexual unsure other prefer not to answer Do you have children? Yes or No If yes, list ages and gender: History of Present Problem: How long have you had the above checked symptoms? How often do these symptoms present? Past Psychiatric History: Outpatient treatment: Yes or No If yes, Please describe when, by whom, and nature of treatment. Reason/ Dates / Treated By Whom: Psychiatric Hospitalization: Yes or No If yes, describe for what reason, when and where. Reason/ Date / Hospitalized Where:
3 Past Psychiatric Medications: Please indicate if you are currently taking or have taken any of the following medication. Antidepressants: Prozac (fluoxetine) (Past/Present) Zoloft (sertraline) (Past/Present) Luvox (fluvoxamine) (Past/Present) Paxil (paroxetine) (Past/Present) Celexa (citalopram) (Past/Present) Lexapro (escitalopram) (Past/Present) Effexor (venlafaxine) (Past/Present) Cymbalta (duloxetine) (Past/Present) Mood Stabilizers: Tegretol (carbamazepine) (Past/Present) Lithium (Past/Present) Depakote (valproate) (Past/Present) Lamictal (lamotrigine) (Past/Present) Antipsychotics/Mood Stabilizers: Seroquel (quetiapine) (Past/Present) Zyprexa (olanzepine) (Past/Present) Geodon (ziprasidone) (Past/Present) Abilify (aripiprazole) (Past/Present) Clozaril (clozapine) (Past/Present) Wellbutrin (bupropion) (Past/Present) Remeron (mirtazapine) (Past/Present) Serzone (nefazodone) (Past/Present) Anafranil (clomipramine) (Past/Present) Pamelor (nortrptyline) (Past/Present) Tofranil (imipramine) (Past/Present) Elavil (amitriptyline) (Past/Present) Other Tegretol (carbamazepine) (Past/Present) Topamax (topiramate) (Past/Present) Other Haldol (haloperidol) (Past/Present) Prolixin (fluphenazine) (Past/Present) Risperdal (risperidone) (Past/Present) Other Sedative/Hypnotics: Ambien (zolpidem) (Past/Present) Sonata (zaleplon) (Past/Present) Rozerem (ramelteon) (Past/Present) Restoril (temazepam) (Past/Present) Desyrel (trazodone) (Past/Present) Other ADHD medications: Adderall (amphetamine) (Past/Present) Concerta (Past/Present) Ritalin (methylphenidate) (Past/Present) Strattera (atomoxetine) (Past/Present) Other Antianxiety medications: Xanax (alprazolam) (Past/Present) Ativan (lorazepam) (Past/Present) Klonopin (clonazepam) (Past/Present) Valium (diazepam) (Past/Present) Buspar (buspirone) (Past/Present) Other Trauma History: Do you have a history of being abused emotionally, sexually, physically or by neglect? Yes or No Please describe when, where and by whom:
4 Family Psychiatric History: Has anyone in your family been diagnosed with or treated for: Bipolar disorder Schizophrenia Depression PTSD Suicide Anxiety Anger Violence Substance Abuse If yes, who had each problem? Past Medical History: Allergies: Current Weight: Height: List ALL current prescription medications and how often you take them: (if none, check this box ) Medication Name: Current over-the-counter medications or supplements: Current medical problems: Past medical problems, nonpsychiatric hospitalization, or surgeries: Personal and Family Medical History: If No Medical Problems, Please check here: You Thyroid Disease Anemia Liver Disease Chronic Fatigue Kidney Disease Diabetes Asthma/respiratory problems Stomach or intestinal problems Cancer (type) Fibromyalgia Heart Disease Epilepsy or seizures Chronic Pain High Cholesterol High blood pressure Head trauma Family History Which Family Member? Other Medical Problems: Is there any additional personal or family medical history? Yes or No If yes, please explain:
5 Substance Use: Have you ever been treated for alcohol or drug use or abuse? Yes or No If yes, for which substances? If yes, where were you treated and when? How many days per week do you drink any alcohol? What is the least number of drinks you will drink in a day? What is the most number of drinks you will drink in a day? In the past three months, what is the largest amount of alcoholic drinks you have consumed in 1 day? Click here to enter text. Have you ever felt you ought to cut down on your drinking or drug use? Yes or No Have people annoyed you by criticizing your drinking or drug use? Yes or No Have you ever felt bad or guilty about your drinking or drug use? Yes or No Have you ever had a drink/drugs first thing in the morning to steady your nerves or to get rid of a hangover? Yes or No Do you think you may have a problem with alcohol or drug use? Yes or No Have you used any street drugs in the past 3 months? Yes or No If yes, which ones? Have you ever abused prescription medication? Yes or No If yes, which ones and for how long? Check if you have ever tried the following: Methamphetamine Cocaine Stimulants (pills) Heroin LSD or Hallucinogens Marijuana Pain killers (not prescribed) Methadone Tranquilizer/sleeping pills Alcohol Ecstasy Other How many caffeinated beverages do you drink a day? Coffee Sodas Tea Tobacco History: Have you ever smoked cigarettes? Yes or No Currently? Yes or No In the past? Yes or No Packs/Day on average? How many years? How many years did you smoke? When did you quit? Why? Family Background and Childhood History: Were you adopted? Yes or No When your mother was pregnant with you, were there any complications during pregnancy/birth? List your siblings and their ages:
6 Did your parents' divorce? Yes or No If so, how old were you when they divorced? If your parents divorced, who did you live with? Do you get along well with your family? Who do you go to for support? Describe your relationship with your spouse or significant other: Have you had any prior marriages? Yes or No If so, how many? Developmental History: Any Developmental/Cognitive Delays? Have you ever needed special education or any special accommodations? Your Exercise Level: Do you exercise regularly? Yes or No If yes, What kind of exercise do you do? How many days a week do you get exercise? Educational History: Highest Grade Completed? Did you attend college? Yes or No What is your highest educational level or degree attained? Occupational History: Are you currently: Working Student Unemployed Disabled Retired What is/was your occupation? Where do you work? Legal History: Have you ever been arrested? Yes or No Do you have any pending legal problems? Yes or No If yes, please describe: For women only: Date of last menstrual period / / Are you currently pregnant or do you think you might be pregnant? Yes or No Are you planning to get pregnant in the near future? Yes or No
7 Birth control method (if any): How many times have you been pregnant? How many live births? Date and place of last physical exam: Is there anything else that you would like us to know? Signature Date: / / Guardian Signature (if under age 18) Date: / / For Office Use Only: Reviewed by Date _ Reviewed by Date _
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