ABHS INTAKE DATA FORM (rev. 03/13/2021)

ABHS INTAKE DATA FORM
Today's Date:

Month Day Year
Date
1. Personal Identification Information
Client's Name:
Gender Identification:
Sexual Orientation (Optional):
Date of Birth:

Month Day Year
Date
Age:
Marital Status:
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone:

Area Code Phone Number
Work Phone:

Area Code Phone Number
Cell Phone:

Area Code Phone Number
E mail Address:
example@example.com
Would you like to receive appointment reminders via email?
Are we permitted to contact you via Text Message regarding appointments?
What is the best way to contact you?
Is it okay to leave a message if you are not available?
Employer's Name and Address:
Emergency contact person:
Relationship to you:
Phone number of emergency contact:
Who Referred you to this agency?
2. Parent/Legal Guardian Information
Please complete this section only if you are under the age of 18 years.
Name(s) of Parent(s) / Guardian(s):
Relationship to you:
Address:
City/State/ZIP:
Home Phone:
Work Phone:
Cell Phone:
Employer(s):
3. Spouse/Partner
Please complete this section only if you are married or in a committed relationship.
Name of Spouse / Partner:
Date of Birth:

Month Day Year
Date
Address (if different from yours):
Home Phone:
Work Phone:
Cell Phone:
Employer(s):
4. Insurance Information
Primary Insurance:
Phone:
Member ID#:
Group #:
Effective Date:

Month Day Year
Date
Insured's Name

First Name Last Name
DOB:

Month Day Year
Date
Insured's Address:
Insured's Phone:
Secondary Insurance (If applicable):
Phone:
Member ID#:
Group #:
Effective Date:

Month Day Year
Date
Insured's Name:
DOB:
Insured's Address:
Insured's Phone:
Person Responsible for Payment:
5. Family Data

	Living?	Age	Gender Identification
Parent #1
Parent #2
Sibling
Sibling
Sibling
Sibling
Sibling
Child
Child
Child
Child
Child

6. Health Information
Name of Primary Care Physician:
Physician Phone:
Physician Office Address:
If you give us permission to contact your Primary Care Physician to coordinate care, please sign your name and date below:
Signature

Clear
Date

Month Day Year
Date
Name of Psychiatrist (or Psychiatric Nurse Practitioner):
Phone:
Office Address:
If you give us permission to contact your Psychiatrist or Psychiatric NP to coordinate care, please sign your name and date below:
Signature

Clear
Date:

Month Day Year
Date

Medications:

	Medication Name	Dosage	Date Began	Who Prescribed?	Purpose
-
-
-
-
-
-
-
-
-
-
-
-

Please check if you or anyone in your immediate family (parents, siblings, children) has had any of the following conditions:

	Self	Family
Alcoholism
Allergies
Anorexia/Bulimia
Anxiety
Arthritis
Asthma
Bipolar Mood Disorder
Cancer
Depression
Developmental Disability
Diabetes
Drug Abuse
Heart Disease
High Blood Pressure
Liver Problems
Multiple Sclerosis
Obsessions/Compulsions
Physical Abuse
Physical Disability
Psychiatric Hospitalization
Seizures
Sexual Abuse

Other Conditions: Please indicate if you or anyone in your immediate family (parents, siblings, children) has had any other conditions.
(6—Health Information, Continued)
How would you rate your present health?
When did you last visit a physician, and why?
Please list any current physical symptoms or illnesses:
How much alcohol do you typically drink in the course of a week?
How often do you use other, “recreational” drugs (for example, marijuana, cocaine, etc?
Has alcohol or other drug use ever caused financial, social, legal, medical, emotional, or other problems for you?
If "Yes," when was that?
Do you smoke cigarettes?
If "Yes", how many per day?
If "No" have you smoked cigarettes regularly in the past?
How many times do you exercise per week?

0 1-2 3-4 4+
Are you on any kind of special diet?
If "Yes," please describe:
7. Treatment History

If you have have ever seen a psychologist or other counselor for a psychological or emotional issue, please provide the following details

	Approximate Dates of Treatment	Type of treatment (medication, counseling, CBT, etc )	Approximate number of sessions	Reason
-
-
-
-
-
-
-
-

Have you ever been hospitalized in an inpatient setting for a psychological or emotional issue?
If "Yes," when and for what reason?
Have you ever been treated for drug or alcohol abuse or dependence?
If "Yes" when and for what substance(s)?
Have you ever attempted suicide?
If "Yes," how and when?
8. Problem Checklist

Please indicate which issues are problematic for you at this time by selecting an option.

	(1) Not a Problem	(2) Minor Problem	(3) Important Problem	(4) Most Important
1. Problems between husband/wife, romantic partners
2. Family problems, parenting problems, children’s behavior, problems with parents, brothers, sisters
3. Problems with social skills, social life, finding friends, getting along with others
4. Trouble coping with emotions such as anger, depression, anxiety, stress, withdrawal, etc.
5. Problems with sexual functioning
6. Problems with alcohol, drugs, food, or gambling
7. Legal problems, such as divorce, custody, arrests
8. Home management, care of the house & family members
9. Health Concerns
10. Money and budgeting problems
11. Job or school related problems, such as job dissatisfaction, poor performance, unemployment
12. Domestic violence, physical/sexual abuse (past or current)

13. Other issues/problems and importance:
9. Degree of Distress/Disruption, & Treatment Expectations
Overall, to what degree are your current concerns disrupting your daily life? (Please check one.)

I feel immobilized much of the time; it is very hard to cope My concerns affect me a great deal; they bother me much or most of the time They affect me to a considerable degree; they interfere with my performance They affect me to some degree; they bother me somewhat These concerns bother me slightly or not at all
How long do you expect it will take for your needs to be satisfied in treatment?
10. Strengths, Supports, Leisure
Where do you find support? (Please include friends, family, community involvements, and spiritual connections)
What do you do in your spare time? (Please include hobbies and other interests)
How much education have you completed?
What are your personal strengths?
Should be Empty:

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ABHS INTAKE DATA FORM

1. Personal Identification Information

2. Parent/Legal Guardian Information

3. Spouse/Partner

4. Insurance Information

5. Family Data

6. Health Information

(6—Health Information, Continued)

7. Treatment History

8. Problem Checklist

9. Degree of Distress/Disruption, & Treatment Expectations

10. Strengths, Supports, Leisure