Psychiatric Intake Form
Name
*
First Name
Last Name
Today's Date
*
/
Month
/
Day
Year
Date of birth
*
/
Month
/
Day
Year
Date
Age
*
Gender Identity
*
Primary Phone Number
*
May we leave a message?
*
Yes
No
Marital Status
Children?
Please list who currently lives with you
*
Last grade completed
*
Are you currently in school?
*
Yes
No
Were there any learning disabilities?
*
Are you currently working?
Yes
No
If yes, what is your occupation?
Military History?
Yes
No
Have you previously sought psychiatric treatment (therapy or medication management, etc.) in the past? List any past medication trials.
*
Are you currently in therapy and if so please provide the name and contact information below:
Therapist First Name
Therapist Last Name
Therapist Phone Number
Please enter a valid phone number.
Please check if we have consent to contact the above provider:
Yes
No
What is the main reason for having a visit with us today?
*
Please check any of the following symptoms you are currently experiencing:
*
Behavioral Issues
Weight Loss/Gain
Forgetfulness
Easily Distracted
Panic Attacks
Alcohol Abuse
Excessive Crying
Trauma
Low Motivation
Substance Abuse
Overwhelmed
Guilt/Self Depreciation
High Risk Behaviors
High Energy
Low Energy
Irritability
Feeling Sad
Poor Concentration
Aggression
Impulsivity
Have you ever experienced suicidal thoughts?
*
Yes
No
Have you had a suicide attempt?
*
Yes
No
What are your current life stresses? Briefiely describe
*
Sleep behavior- please check all that apply:
Sleep Walking
Nightmares/Night Terrors
Midnight Awakenings
Difficulty Falling Asleep
If you checked yes to any of these, please describe
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Medical History
Primary Doctor
Primary Doctor Phone Number
Current Pharmacy
*
Pharmacy Phone Number
*
Current Weight
*
Current Height
*
Date of last physical exam?
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Month
/
Day
Year
Have you had any prior abnormal labs or tests?
Current medical problems, include any medical medications taken at this time
Past releveant medical history and medications
Any history of head trauma or seziures?
Prior hospitalizations (medical or psychiatric)?
Any major surgical procedures?
Allergies/ drug intolerance?
Patient/Guardian Signature
*
Submit
Should be Empty: