Adult Intake Form
Patient Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Marital Status
*
Single
Married
Separated
Widowed
Other
Educational Level
*
Occupation
*
Do you have any children?
*
Yes
No
Please list emergency contact information (name and phone number)
*
Financial Information
Annual household income
*
Areas of Concern
What is/are the reason(s) you are seeking therapy? Please be detailed as much as you can
*
What do you think is the Primary Problem that needs to be worked out so your life improves?
*
Please check any of the following symptoms you have experienced in the past 6 months:
*
increased appetite
decreased appetite
trouble concentrating
difficulty sleeping
excessive sleep
low motivation
isolating from others
fatigue/low energy
low self esteem
depressed mood
tearful or crying spells
worry thoughts
hallucinations
delusions
paranoia
Do you have specific goals regarding your treatment?
*
Do you have any particular concerns/fears with regards to treatment?
*
Mental Health History
Have you ever received mental health treatment before?
*
Yes
No
If yes, please answer the following: When and for how long, focus of treatment and name of treatment therapist
Have you ever been hospitalized for mental or emotional problems?
*
Yes
No
If yes, please answer the following: When and for how long, why were you hospitalized, Name of hospital
Are you taking any prescription medication(s) for a mental or emotional condition?
*
yes
no
If yes, please answer the following: Prescribed by whom, Name of medications and how long have you been on the medication
Were you ever subjected to verbal, physical, emotional, sexual abuse? Please describe
*
Have you ever been a victim of a violent crime? Please describe
*
Medical History
Do you have any medical conditions that may affect your mental health treatment?
*
Are you currently taking any prescription medication?
*
Yes
No
If yes, please answer the following: Prescribed by whom, Name of medication and how long you been on the medication
Are you experiencing any medical/physical symptoms you attribute to a mental, emotional or stress related condition? Please describe
*
Please describe your overall health
*
Substance Abuse History
Have you ever been in a 12 step program?
*
yes
no
Do you smoke cigarettes?
*
Yes
No
If yes, please answer the following: How much and for how long?
Do you drink alcohol?
*
yes
no
If yes, on average, how much alcohol do you consume in a week?
Have you ever used drugs? Please describe
*
Do you currently use drugs? Please describe your use
*
Family History
Please describe your childhood?
*
Is there a family history of mental illness? If so, please describe
*
Please provide information about your mother. Describe your relationship with her?
*
Please provide information about your father. Describe your relationship with him
*
Other Information
Please describe your spiritual identity/orientation
*
Are you satisfied with your social situation/interpersonal relationships?
*
yes
No
If no, please describe why not
Please describe your interests/hobbies
What do you consider your strengths? What do you like most about yourself?
*
What are your effective coping strategies you use when stressed?
*
Please feel fee to include any other information that you believe is relevant to your mental health treatment
*
E-signature: I consent to sharing information provided here
*
Today's date
*
-
Month
-
Day
Year
Date
Submit
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