Intake Information Form

Intake Information Form First Name: MI: Last : Birth date: / / Referred by: Insurance / other: Address: City:, Zip: living with: phone: (H): (W): (C): Email: Occupation: FT / PT since: Student: yes / no at FT / PT since: Retired: yes / no, Disabled: yes / no, Last type of employment: Dates: Relationship status: Married since In a Committed Relationship since Divorced since Separated since Widowed since Never married I have never been in a marriage/partnership Dating Engaged Single Not currently in a relationship Other: Sexual orientation: Gender identity (male, female, transgender, queer, questioning, ect.): Reason for appointment :. Please describe when your most recent symptoms began: Recent stressors: (finances / housing / relationships / work) Current psychiatric medications (if taking any), are prescribed by:, since Are your psychiatric medications helpful yes / no Are you switching therapists? yes / no If yes, why? What mental health diagnosis have you been given in the past? How would you rate your overall mood over the past month on a scale of 1-10, ( 1 = not good, 10 = very good): / 10 At what age do you recall having FIRST experienced these symptoms, or any mental health symptoms, ever in your life: Age Please describe these symptoms: The FIRST time that you entered Mental Health care treatment (of any type, counseling, hospitalization, or medication, etc.): Age Please describe: What are your strengths? 1

Mood: Generally good Lower than usual Depressed / very low Irritable Easily angered Difficulty being hopeful Hopeless Fluctuates, If it fluctuates, does it change drastically, hourly, daily, weekly or monthly, with intense highs feeling euphoric and or irritable, and then extreme lows? yes / no If yes, please describe: Does your mood change with the seasons: yes / no If yes, describe: Interests/desire to participate in things you normally enjoy doing: Good Declining Poor Absent No motivation Energy: Generally good Higher than usual Lower than normal Poor Difficult to even function- no energy Regular exercise: Yes No if yes, describe: Sleep: Good / well-rested Difficulty falling asleep Difficulty staying asleep Early awakening Restless legs Sleeping too much Not feeling well-rested Other sleep issues: Concentration: Generally good More difficult recently Problems most of the time Did you have difficulty with concentration, focus or hyperactivity dating back to at least grade school (before age 7): yes / no If yes, describe: Have you or family members or teachers ever suspected that you have Attention Deficit Disorder (ADD or ADHD)? yes / no Appetite: Consistently good Increased Decreased Fluctuates Emotional eating Binge eating Poor-no appetite Libido: Consistently good Increased Decreased Fluctuates Concerning/upsetting for me Concerning/upsetting for my partner/s Have you ever had an eating disorder: yes / no If yes; Anorexia / restricting Bingeing Vomiting Laxative abuse Excessive exercising If so, between what years did you struggle with an eating disorder? Feelings of Guilt or shame: Yes No if yes, describe: How is your overall self esteem: Generally good Better than most Lower than normal Poor Worthless Anxiety: Never has been an issue Past problem-not now Constant worry-often anxious Anxious only in certain situations/locations or about a specific object or topic I tend to obsess about needing to do a particular behavior, and can only decrease these feelings by actually doing the behavior (checking, counting, hand washing, picking, etc) If yes, describe: Panic: Never has been an issue Past attacks-not now Frequently experiencing attacks how often: Unable to leave the house secondary to worrying about having an attack Attacks only occur when triggered by a certain situation - describe: Trauma /Abuse: Have you ever had your life threatened to the point where you thought you might die, or witnessed anything horrific? yes / no If yes, do you currently experience: Sudden feelings/emotions that make you feel as if you are re-living the event Intrusive thoughts especially if triggered by a sight, sound or smell that reminds you of the event Nightmares Extremely guarded difficulty trusting others Abuse history: yes / no If yes, was it: Sexual Physical Emotional Neglect Other: How old were you, or between what ages/years did it occur, and by whom? Was it reported? yes / no Does it negatively affect your ability to function today? yes / no Hallucinations? Do you hear voices, or see things that are difficult to explain? yes / no / past problem If yes- or a past problem 2

please describe: Paranoid feelings? yes / no / past problem If yes, or a past problem, please describe: Fixed beliefs that no one seems to believe? yes / no / past problem If yes, or a past problem, please describe: Self injurious behaviors (cutting, burning, etc, not meant to kill yourself): yes / no If yes, describe, including between what age/s this occurred, and when was the last time you participated in this behavior: Have you ever attempted suicide? yes / no If yes, how many times, at what age/s, and how did you attempt: Do you CURRENTLY have thoughts of suicide, or plans to complete suicide? yes/no; Do you have any history of being violent or assaulting physically hurting anyone? yes / no If yes, describe: Do you have any guns in the home? yes / no If yes, do you have access to these guns? yes / no Do you have any current legal issues? yes / no If yes, describe: Do you anticipate that your treatment records will be used in court? yes / no If yes, describe: Are you currently involved in a pending law suit or other court-related actions? yes / no If yes, describe: Have you ever been arested? yes / no If yes, describe: MEDICATIONS, VITAMINS & OVER-THE COUNTER (w/ dosage): Date started Side effects (if any) 1. 4. 5. 6. 7.Contraception: None Oral birth control Tubal Depo IUD Condoms Patch Other: (If additional medications, please attach a list of your medications) PAST PSYCHIATRIC HISTORY: A. Psychiatric Hospitalizations (where): Reason Dates (mo/yr length ) 1. B. Electroconvulsive treatment history: yes / no if yes, where - C. Therapist/s D. Psychiatrist/s E..Mental Health Case Manager / Social Worker: yes / no If yes, who F. Past Psychiatric Medications (I nclude dose if known): Dates taken Reason stopped 1. 4. G. Alcohol - any current, recent or past use: yes / no If yes - please complete the following: Have you ever been dependent on, or abused alcohol: yes / no On average, how many drinks do you have each week? Has anyone ever expressed concern about your drinking? yes / no If yes, who, and when: 3

Have you ever tried to cut down on your drinking? yes / no If yes, when: Have you ever felt guilty about or tried to hide your drinking? yes / no If yes, when: Have you ever experienced black outs while drinking? yes / no If yes, when: Have you ever experienced withdrawal seizures when you have cut down or stopped drinking? yes / no If yes, when: _ Has alcohol ever caused you any problems, (relationships, jobs, legal issues, etc)?? yes / no Have you ever received a DUI or DWI? yes / no If yes, when: H. Illicit street drugs any current, recent or past use: yes / no If yes- please complete the following: Have you ever been dependent on, or abused drugs: yes / no How many times in the past year have you used an illegal drug or used a prescription medication for non medical reasons? First use Last use Average use Problematic? Marijuana / Pot / Hash yes / no Cocaine / Crack yes / no Heroin yes / no LSD or Mushrooms yes / no Meth /Amphetamines yes / no IV Drug use yes / no Prescription Drug Abuse yes / no Other yes / no Chemical Dependency Treatment History: yes / no If yes, when and where: Medical / Surgical History: Wt: Height: Weight 1 yr ago: lbs. Ideal weight: lbs. Recent changes in weight? 1. Primary Doctor: Location: Phone: 2. Specialty Doctor: Location: Phone: 3. Most recent Physical Exam Date: to address what issue: 4. Current & Past Medical Problems: 5. Tobacco use: yes / no If yes; packs per day, since what date? 6. Surgery history: 7. Seizure history: yes / no If yes, when: 8. Head trauma w/ loss of consciousness: yes / no If yes, when: 9. Are you trying or planning to become pregnant? yes / no / N/A Last menstrual period started: 10. Have you ever been pregnant? How many births? Do you have children? 11. Has there been a history of perinatal mental health concerns for yourself or a family member? 12. Family History (health problems which were/are present in your biological family (parents, siblings, children, etc): N/A Depression Who: N/A Bipolar disorder (manic-depression) Who: N/A Anxiety / Panic attacks Who: N/A ADHD/ADD (hyperactivity) Who: N/A Schizophrenia Who: N/A Suicide attempts or completions Who: N/A Alcohol or Illicit street drug abuse or dependence Who: N/A Diabetes Who: N/A Cancer Who, and what type: 4

N/A N/A N/A N/A Alzheimer s Dementia Who: Thyroid Disorders Who: Obstructive Sleep Apnea Who: Other Who: Social History: Born (City/State): Raised(City/State):, w/ brothers, sisters, birth order: (1 st, 2 nd, etc.) As a child I lived with: Both parents Single parent: M / F Blended family Other: Mother s type of work: Father s type of work: Parents divorced: yes / no if yes, how old were you? The following significant experiences have happened to me (frequent moving, war experiences, natural disaster, etc.): Education: graduated from High School: yes / no If no, how many years completed?: GED: yes / no / N/A College: yes / no If yes, how many years, did you obtain a degree, and from which college? How would you describe your educational years: Have you ever been diagnosed with a learning disability? yes / no If yes, at what age? and what type? Religious affiliation/spirituality that plays an important role in your life? yes / no If yes, what type? Children: yes / no If yes, list names / ages: Please list the people you would include in your support network; people you can trust and confide in (spouse / significant other / friends / brother / sister / CM/SW / therapist / Mother / Father/ Clergy, etc): Please check all that apply to you: I don t really desire or enjoy close relationships with others. I usually prefer being alone than with other people. I have no close friends (or only one) outside my family. I usually do not experience strong emotions I am often distrustful and suspicious of others. I often expect to be hurt by others. I often question the loyalty of my spouse or friends I am usually unforgiving of other people s insults or slights I have special abilities such as ESP or mind reading. I have often been described by others as odd or weird. I often feel the presence of other people or forces that are not there I am not usually emotional. ********* I have often done things that I could have been arrested for. I often lie to get my own way or things that I want. I have often gotten into physical fights. I have often been unreliable to people who count on me. I was tardy often or in trouble in school. I have been physically cruel to people or animals. I have intentionally destroyed property and/or started fires. I have run away from home more than once. I seem to have unstable and intense relationships I often have intense mood swings. I am often impulsive I often do things in order to avoid being abandoned. I have intense anger or have difficulty controlling my anger. I have done self-destructive behaviors 5

I have been told that I am very emotional I like to be the center of attention I use my physical appearance to attract people. I am very dramatic and often exaggerate expression of emotions. I frequently think relationships are more intimate than they really are. I often exaggerate who I am and things that I do. I think I need excessive attention and admiration. I know I am very special and can only be understood by or associate with other special people. I expect favorable treatment from other people. I feel very angry or embarrassed if I am criticized. ********* I am preoccupied with being criticized or rejected. I don t like to get involved with people unless I know they will like me. I am reluctant to get involved intimately with people because of a fear of being shamed or made fun of. I am reluctant to take risks or engage in new activities because they may be embarrassing. I have difficulty making everyday decision without getting advice from others. I let other people take responsibility for important areas of my life. I have difficulty starting projects or doing things on my own. I am preoccupied with fears of being left to take care of myself. I am a perfectionist and this often interferes with completing tasks. I am preoccupied with details, rules, and organization. I am so devoted to work that I do not take time for friendship or leisure activities. I am very conscientious and do not bend when it comes to morality and values. Person to contact in the event of an emergency: Name: Relationship: Phone: In the event of an emergency, I give authorization to contact the above-named person. Signature: Date: 6