Adult Intake Form. Name: Date: Describe the problem that brought you here today: Briefly share relevant history behind this problem:

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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 Change in Appetite Suspicion/Paranoia Hyperactivity Lack of Motivation Racing Thoughts Impulsivity Withdrawal From People Excessive Energy Boredom Anxiety/Worry Wide Mood Swings Poor memory/confusion Anxiety/Panic Attacks Sleep Problems Seasonal Mood Changes Fear Away From Home Nightmares Sadness/Depression Anxiety in Crowds Eating Problems Loss of Pleasure/Interest Social Discomfort Gambling Problems Hopelessness Obsessive Thoughts Computer Addiction Helplessness Compulsive Behavior Problems with Pornography Thoughts of Death Aggression/Fights Sexual Problems Self-Harm Behaviors Frequent Arguments Relationship Problems Crying Spells Irritability/Anger Parenting Problems Loneliness Intrusive Upsetting Work/School Problems Memories Low Self-Worth Flashbacks Alcohol/Drug Use Guilt/Shame Homicidal Thoughts Spiritual Concerns Fatigue Hearing Voices Acculturation Difficulties Grief Visual Hallucinations Other: Are your problems affecting any of the following? Handling Everyday Tasks Self-Esteem Relationships Hygiene/Self-Care Work/School Housing Legal Matters Finances Recreational Activities Sexual Activity Health Page 1 of 5

Yes No Have you EVER had thoughts, made statements, or attempted to hurt yourself? If so, please describe: Yes No Have you EVER had thoughts, made statements, or attempted to hurt someone else? If so, please describe: Yes No Have you recently been physically or sexually hurt OR threatened by someone else? If so, please describe: PREVIOUS MENTAL HEALTH TREATMENT Yes No Type of Treatment When? Provider/Program/Medication Reason for Treatment Outpatient Counseling Medication (Psychotropics) Psychiatric Hospitalization Drug/Alcohol Treatment Self-Help/Support Groups 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 PCP/LSD Steroids Tranquilizers/Benzos Page 2 of 5

Have you ever felt you ought to cut down on your drinking or drug use? Have people annoyed you by criticizing your drinking or drug use? Have you felt bad or guilty about your drinking or drug use? Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)? Y N N/A FAMILY AND DEVELOPMENTAL HISTORY Relationship Name Age Quality of Relationship Mother Father Stepmother Stepfather Other Guardian(s) Siblings Spouse/Partner Children Family Mental Health Problems Inattention or Hyperactivity Learning Problems Sexually Abused Depression Manic Depression Suicide Anxiety Panic Attacks Obsessive Compulsive Anger/Abusive Schizophrenia Eating Disorder Alcohol Abuse Drug Abuse PTSD Personality Problems Autism Spectrum Who? Parents Legally Married or Living Together Mother Remarried: Number of Times Parents Temporarily Separated Father Remarried: Number of Times Parents Divorced or Permanently Separated Parent(s) Deceased: Please check if you experienced any of the following problems while growing up: Emotional Abuse Neglect Lived in Foster Home Sexual Abuse Violence in the Home Multiple Family Moves Physical Abuse Crime Victim Homelessness Parent Substance Abuse Parent Illness Natural Disaster Teen Pregnancy Placed a Child For Adoption House Fire Rape/Sexual Assault Miscarriage Loss of Loved One Death of Sibling Parent Abandonment Financial Problems Page 3 of 5

PSYCHOSOCIAL HISTORY Please describe your social support network: (check all that apply) Family Neighbors Friends Students Co-Workers Support/Self-Help Groups Community Group Religious/Spiritual Center (which one?) To which cultural/ethnic group do you feel that you belong? If you are experiencing any cultural/ethnic issues, please describe How important are spiritual matters to you? Not at all Somewhat Very Much Would you like spiritual matters to be incorporated into your counseling? Yes No Please describe strengths, skills or talents: Please describe special interests or hobbies: Employment Employer: Position: Length of time in position: Job duties: Stress level in this position: Low Medium High Other jobs you have had: Education Yes No Are you currently attending school? High School Graduate OR GED Year? Associate s Degree Year Major Area of Study Undergraduate Degree Year Major Area of Study Graduate Degree Year Major Area of Study Military and Civil Service Yes No Have you been/are you currently in the military? If yes Branch: Date of Discharge: Type of Discharge: Rank: Did you deploy in combat? Yes No Are you in any other type of civil service? (Police, EMT, Firefighter, USPS, etc) Does your job require specialized medical review? (Aircrew, Top Secret Clearance, etc.) Legal Yes No Have you ever been convicted of any type of misdemeanor or felony? Please explain: Yes No Are you currently involved in any type of divorce or child custody proceedings? Please explain: Page 4 of 5

MEDICAL HISTORY Date of Last Physical Exam: Have you experienced any of the following conditions during your lifetime? Allergies Asthma Headaches Stomachaches Chronic Pain Surgery Serious Accident Head Injury Autoimmune D/O Meningitis Seizures Vision Problems Dizziness/Fainting Diabetes Hearing Problems Miscarriage High Fevers Obesity Heart Disease Abortion Sleep Apnea Hyperlipidemia Parasomnias STDs Hypertension Frequent Nighttime Awakenings Other Chronic Conditions: Please list any current health concerns: Please list any prescription AND over the counter medications or supplements: Medication Dosage Date First Taken Prescribed By (if Rx) Allergies and/or adverse reactions to medications: None If yes, please list medication and reaction: Please share any other circumstances that you wish to make your provider aware of: Thank you for taking the time to complete this history questionnaire! This information is essential for you and the provider to determine the best ways to assist you. Page 5 of 5

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