Pre-Intake demographics and self-Assessment

 

Name *
Name
Today's Date *
Today's Date
Address *
Address
Include Suite/Apt. # on Address line 2 if needed
Phone (Home/Mobile) *
Phone (Home/Mobile)
Phone (Work)
Phone (Work)
Is it ok to leave messages at this number?
Check a box if it is ok to leave messages at these numbers
Please type in numeric form
Date of Birth *
Date of Birth
If you live by yourself please type in N/A
If you answer other, please describe on next line.
Please describe the relationship of the person with whom you live if you have answered other in the drop down above.
Address of emergency contact *
Address of emergency contact
Phone (Home/Mobile) of emergency contact *
Phone (Home/Mobile) of emergency contact
Phone (Work) of emergency contact
Phone (Work) of emergency contact
If you have not been referred by anyone please type in N/A
Please provide the name, location and phone number of your phrmacy.
Please provide the name and location of your primary care provider or type in N/A if you do not have one.
Marital Status *
Education *
Why are you seeking consultation?
Please describe your mental health symptoms or concerns from the time of your first symptom to the present. When did they start? What have you experienced? How has it affected your functioning? What mental health providers and treatment modalities have your worked with before? What psychiatric medications and doses have you taken/been prescribed in the past and how did you respond to each them?
Suicide *
If “yes,” when was the last time? If you checked any of the boxes above other than "I never have thought about suicide", please type when was the last time and how? (Please type your answers in the space provided below)
Injury to Others *
If “yes,” when was the last time? If “yes,” when and how? (Please type your answers in the space provided directly below labeled "comments regarding injury to others")
Recent Stressful Life Events *
Check any of the following events that have occurred during the last 2 years.
Drinking (Alcohol Use) *
How many drinks do you consume in the average week?
Drinking (Alcohol Use)
Check if you ever felt that you were, or someone told you that you were, drinking too much?
If “yes,” to the above question, under what circumstances? Has alcohol use ever negatively impacted your education, work, relationships or mental health?
Drugs of Abuse *
Check if you have taken any of the following drugs.
If you checked one or more of the drugs, under what circumstances did you take it (them)?
Has drug use ever negatively impacted your education, work, relationships or mental health? What is the most frequently you have ever used drugs?
When was the last time you took such drugs?
Prenatal History *
Check any items that apply to you and explain in the space provided below.
Childhood and Adolescent History *
Check any items that apply to you and explain in the space provided below.
Please type in below- Mothers Age (Or if deceased, age at death) Mothers Occupation (Or if deceased, cause of death) Major Illnesses Mother had (List all major illnesses, including psychiatric, neurologic, alcoholism, drug abuse, suicide, and suicide attempts) Type in N/A if not applicable
Please type in below- Fathers Age (Or if deceased, age at death) Fathers Occupation (Or if deceased, cause of death) Major Illnesses Father had (List all major illnesses, including psychiatric, neurologic, alcoholism, drug abuse, suicide, and suicide attempts) Type in N/A if not applicable
Please type in below- Brothers Age (Or if deceased, age at death) Brothers Occupation (Or if deceased, cause of death) Major Illnesses Brother had (List all major illnesses, including psychiatric, neurologic, alcoholism, drug abuse, suicide, and suicide attempts) Type in N/A if not applicable
Please type in below- Sisters Age (Or if deceased, age at death) Sisters Occupation (Or if deceased, cause of death) Major Illnesses Sister had (List all major illnesses, including psychiatric, neurologic, alcoholism, drug abuse, suicide, and suicide attempts) Type in N/A if not applicable
Please type in below- Grandparents, uncles, and aunts Age (Or if deceased, age at death) Grandparents, uncles, and aunts Occupation (Or if deceased, cause of death) Major Illnesses Grandparents, uncles, and aunts had (List all major illnesses, including psychiatric, neurologic, alcoholism, drug abuse, suicide, and suicide attempts) Type in N/A if not applicable
Weight Changes
Check if your weight has changed by 10% or more in the past 6 months.
If checked above, explain circumstances.
Sleep History *
Check if you...
Tobacco Use History *
How much and for how long?
Medical History (Caffeine) *
Check if you drink coffee, tea or colas
If you indicated that you use caffeine above, how frequently and how much?
Please list all prescription and over the counter medications and supplements you are currently taking. Please also list any medication allergies. If you are not taking anything, please write N/A in the box below.
List all past and present medical problems as well as any surgery or accidents and the age when it first occurred.
Females, Menstrual History
Females, Pre-menstrual Symptoms
Check any that occur with increased intensity or frequency in the week preceding your period.
Please describe the symptoms above
Use of Hormonal Contraceptive
If you checked the box above, please explain which one, for how long, and if you have noticed any potential impact on your thoughts, feelings or behavior you have noticed.