People In Need Adult Intake Information Form (18 years old and up)
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1 People In Need Adult Intake Information Form (18 years old and up) Date: Name: Client Case # Sex: Date of Birth: Social Security Number: - - Home Address: Work Address: Employer: Occupation: Referred by: Please contact me by: Home Phone: Cell Phone: Work Phone: Emergency Contact Person: Relation: Phone: Address: Describe the reason for your visit: Family and Household Composition: (List all immediate family members/significant relationships. In Location column, write H for people living in your household and write city/state of residence for people not in your household. Under Health Issues, write any serious illness or injuries). NAME RELATIONSHIP AGE LOCATION HEALTH ISSUES Martial and Relational History: Never married In a current relationship, how long? Married Date: Separated Date: Divorced Date: 2 nd Marriage Date: 2 nd Divorce/Separation Date: Widowed Date: Spouse/Partner Name: Age: Occupation: Children? No Yes how many:
2 Please list any significant stressors that you have experienced (accidents, deaths, moves, job change/loss, illness, injury, family/marital problems, violence, crime, victimization, living arrangements): Educational History: Highest grade completed: School: Year: Diploma GED Vocational training: School: Year: College: Highest degree completed: School: Year: Military: Branch: Dates: Status: Employment History: EMPLOYER JOB TITLE LENGTH OF CURRENTLY EMPLOYMENT EMPLOYED? Have you ever been given warnings or let go from a job because of job performance? If yes, explain: Problems preventing you from maintaining steady employment: History of Sexual, Physical, or Psychological Abuse: Sexual abuse Raped Victim of domestic violence Physical abuse Psychological abuse Sexual activity with a family member or relative Have you ever experience any kind of sexual, physical, or psychological abuse as a child, adolescent, or adult (describe nature of abuse, how long, age, people involved, charges filed/reporting of incident)?
3 Please list any previous MENTAL HEALTH SERVICES (residential, inpatient, partial, and/or outpatient): PROVIDER/AGENCY DATES REASON Please list any previous/current SUBSTANCE ABUSE TREATMENT services (inpatient, IOP, and/or outpatient): PROVIDER/AGENCY DATES REASON Please list any SYSTEMS INVOLVEMENT and/or intervention (social services, CYS, domestic relations): TYPE OF INVOLVEMENT DATES OUTCOME Please list any past and pending LEGAL MATTERS (criminal, DUI, civil, custody/visitation, divorce, disability): LEGAL HISTORY DATES OUTCOME
4 Health Information Primary Care Physician: Height: Weight: Have you had any seizures or convulsions: No Yes, please explain when and what caused them: Allergies: No Yes, please list: Current health problems or concerns: PROBLEM/CONCERN HOW LONG NAME OF TREATING DOCTOR Medical Hospitalizations (especially involving head/neck/spine): FOR SURGERIES OUTCOME/STATUS DATE(S) FOR MAJOR ILLNESS/INJURY TREATMENT/OUTCOME DATE(S) Family Psychiatric/Medical History (major illness or disease that runs in the family): FAMILY MEMBER(S) ILLNESS/DISEASE TREATMENT STATUS/OUTCOME
5 Current Medications/Medications taken within the year (prescribed and non-prescribed): MEDICATION DOSE/FREQUENCY REASON SIDE EFFECTS Lifestyle/Health Habits: Hours of sleep per night: Describe any sleep problems: Exercise/physical activities (how often, how long, what type): Describe any problems with appetite: Any significant changes in weight (20+ lbs. in 6 months): No Yes, please describe and give any reasons for change: Interests/Hobbies: Women Only: Age you began to menstruate: Explain any problems with menstruation: Explain any menopause symptoms/treatment: YES/NO IF YES, HOW MANY DATE(S) Pregnancies Miscarriages Abortions Men Only: List any problems with prostate/painful urination/impotence:
6 Substance Use History (please check all past/present use): Average daily consumption of coffee, tea, cola, or other caffeine: No tobacco use Former tobacco user who has quit, when: Tobacco user (cigarettes, cigars, chew, snuff, e-cig) Average daily tobacco use: Are you on Methadone maintenance: No Yes, Clinic: Are you on Suboxone maintenance: No Yes, Clinic: Substance Age at Date of last Frequency/Length Method Quantity first use use Alcohol Tranquilizers (Ativan, Xanax) Marijuana Heroin Other opiates (OxyContin, Vicodin, Percocet) Cocaine/Crack Methamphetamine Amphetamine (speed) LSD MDMA (ecstasy) PCP Inhalants Over the Counter (cough syrup, caffeine pills) Client/Guardian Signature: Date: Therapist Signature: Date:
Name: Gender: male female Age: Date of birth: / / Preferred phone: cell home work other. Alternate phone: cell home work other.
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