Initial Intake Screening Form
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Identified Gender
Marital Status
Phone Number
Please enter a valid phone number.
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Nunmber
Please enter a valid phone number.
Pharmacy Name:
Pharmacy Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pharmacy Phone Number
Please enter a valid phone number.
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Past Family & Medical History
Important Family Members
Name
Relationship
Age
In same household? (Y/N)
1
2
3
4
5
6
7
8
Have you or anyone in your family experienced the following?
Self
Family
Comments
Anxiety
Panic Attacks
Bipolar Disorder
Depression
Suicidal ideations/attempts
Hallucinations
Paranoia
Schizophrenia
Thoughts of harming self
Thoughts of harming others
Anger problems/violence
Eating disorder
Emotional/verbal abuse
sexual abuse
physical abuse
attention deficit
Substance Abuse (specify)
Past and current mental health services:
Yes/No
Agency/Provider
Dates
Outpatient
Wraparound services
family-based
partial hospitalization
inpatient hospitalization
Drug and Alcohol treatment
Past and Current Medications
Name of Medication
Currently prescribed? (Y/N)
Dosage Frequency
Diagnosis condition
Prescribed by
Dates
1
2
3
4
5
6
7
8
9
10
Has there been any changes to your medication in the past 60 days?
Yes
No
If yes, explain
Are you currently experiencing any side effects from your medication?
Yes
No
If yes, please explain:
Have you had past side effects from specific medications?
Yes
No
If yes, please specify reaction & medication:
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Medical History
Primary Care Physician:
First Name
Last Name
Primary Care Physician Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PCP Phone Number
Please enter a valid phone number.
Date last seen:
-
Month
-
Day
Year
Date
Are you pregnant?
Yes
No
N/A
Have you had a physical health problem in the last year?
Yes
No
If Yes, Specify
Do you have any current physical conditions, problems or concerns?
Yes
No
If yes, please specify concenrs
Do you currently have any allergies to any foods, medications, or environmental conditions?
Yes
No
If yes, please specify:
Have you or a family member had a history of any of the following diseases/illnesses? (if yes, please indicate who in the family)
Yes
No
Specify Who
Explain/details
Heart problems
High or low blood pressure
Stroke
Cancer (type)
Arthritis
Epilepsy
Diagbetes
Anemia
Kidney problems
Eye/Ear problems
Liver conditions
Lung//Breathing problems
Thyroid condition
Sexual transmitted disease
Other:
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Safety Assessment:
Do you have current thoughts about harming or killing yourself?
Yes
No
If yes, please describe:
***IF EXPERIENCING ACTIVE THOUGHTS TO KILL YOURSELF, PLEASE CONTACT 911 OR PROCEED TO THE NEAREST EMERGENCY ROOM
Do you, or have you, had thoughts that you would be better off dead or wished you were dead?
Yes
No
If yes, please indicate if you have a current safety plan or if you are able to contract for safety:
Have you thought about, or tried, killing yourself in the past?
Yes
No
If yes, please describe previous attempt/plan and outcome such as hospitalization, medication, treatment
Have you ever cut yourself or hurt yourself on purpose?
Yes
No
If yes, please describe
Any past history or thoughts/attempts to hurt others?
Yes
No
If yes, please describe:
Do you have any history of violence or aggression?
Yes
No
If yes, please describe:
Have you ever experienced hearing or seeing things that others do not?
Yes
No
If yes, please describe:
Have you ever had any concerns about your weight that have caused you to restrict your diet, exercise excessively, binge, make yourself vomit, or use diuretics or laxatives?
Yes
No
If yes, please indicate type and most recent episode along with any history of treatment:
Substance Abuse:
Do you believe you have an alcohol or drug problem?
Yes
No
Have family/friends ever told you that they thought you had an alcohol or drug problem?
Yes
No
Have you experience any consequences as a result of your substance usage? (IE loss of employment, trouble in school, legal issues, impact on relationships, impact on health)
Yes
No
If yes, please explain:
Have you ever used more than intended
Yes
No
Have you experienced withdrawal symptoms in the past?
Yes
No
If yes, please mark all that you have experienced:
Diarrhea
Chills/Sweats
Tremors/Shaking
Irritability
Nausea/Vomiting
Anxiety
Weakness
Hallucinations
Tachycardia
Increased Blood Pressure
Other
What is your longest period of clean time?
Have you ever received treatment for substance abuse in the past?
Yes
No
If yes please describe:
Have you ever been treated with Suboxone, Buprenorphine, Naltrexone, or Campral?
Yes
No
If yes, please describe:
SUBSTANCES USED
Age of 1st use
Date of last use
Frequency/amount of use
Alcohol
Marijuana/Hash
Opiates
Heroin
Cocaine/Crack
Benzodiazepines
Amphetamines
Inhalants
Hallucinogens
OTC
Club Drugs
NIcotine
Submit
Should be Empty: