Mental Health Intake Form
Patient name
*
First Name
Last Name
Patient date of birth
*
-
Month
-
Day
Year
Date
Who should form be sent to/who is your appointment with?
*
Agganis, Georgia
Aldrich, Meghan
Amin, Priyal
Athanasiou, Andreas
Balestrieri, Karen
Coleman, Russell
Daly, James
Eagan, Joan
Foley, Megan
Goharfar, Behzad
Grossman, Emily
Hall, Alexandra
Hiltunen, Karen
Hohmann, Deanna
Jackson, Patricia
Jensen, Susan
Jones, Eliza
Kelleher, Susan
Laurin Kinney, Jayne
Leonhardt, Julie Bonner
Narayan, Sara
Oliver, Dana
Scott, Kendra
Sheehy, James
Stimpson, Devin
Suriani, Christine
Triehy-Kreitler, Ashley
Voute, Susan
Wilson, Kathryn
*** Other ***
Form completed by/Relationship to patient
*
Please list the reason for your visit/referral today
Current Medications
Psychiatric Medications:
Name
Dose
Frequency
When started
Prescribed by
1
2
3
4
Non-psychiatric Medications (prescription):
Name
Dose
Frequency
When started
Prescribed by
1
2
3
4
Over the counter Medications:
Name
Dose
Frequency
When started
Prescribed by
1
2
3
4
Medication/drug allergies:
Psychiatric History
Hospitalizations:
Yes
No
Total number of hospitalizations:
Age at first hospitalization:
List three most recent hospitalizations starting with most current:
Name
Dose
Frequency
Started & Stopped
Reason for stopping
1
2
3
4
5
List three most recent counselors/therapists starting with most current:
Name
Facility
Dates
Results
most recent
second most recent
third most recent
List any prior medication evaluations:
Name
Facility
Dates
Results
most recent
second most recent
third most recent
List any previous medications (no longer being taken)
Name
Facility
Dates
Results
most recent
second most recent
third most recent
Family History
Illness:
BIOLOGICAL MOTHER
BIOLOGICAL MOTHER’S FAMILY
BIOLOGICAL FATHER
BIOLOGICAL FATHER’S FAMILY
SIBLINGS
OTHER
MENTAL RETARDATION
SEIZURE DISORDER
DEPRESSION
SCHIZOPHRENIA
ANXIETY
ADHD
LEARNING DIFFICULTIES
BEHAVIORAL PROBLEMS
ALCOHOL OR DRUG DEPENDENCY
Trauma History
Has your child had any frightening or traumatic experiences? If yes, please describe:
Click for 'yes'
Details
Accident
Medical Trauma
Other
Has your child ever experienced sexual or physical abuse? If yes, please describe:
Click for 'yes'
Details
Physical abuse
Sexual abuse
Sexual assault
Neglect by parent(s)
Neglect by relative(s)
Has your child ever been a witness to violence? If yes, please describe:
Click for 'yes'
Details
Witness to domestic violence
Witness to other violence
Substance abuse history
Substance
DATE OF LAST USE
AGE OF FIRST USE
METHOD OF USE
AMOUNT/ FREQUENCY OF USE
TYPE
ALCOHOL
MARIJUANA
TOBACCO
COCAINE
PCP
HEROIN
SEDATIVES
AMPHETAMINES
PRESCRIPTION
DRUGS
INTERNET
VIDEO GAMES
OTHER
Yes
No
Have you ever felt the need to cut down on your drinking?
Have you ever felt annoyed by the criticism of your drinking?
Have you ever felt guilty feelings about drinking?
Have you ever taken a morning eye opener?
Have you ever been to a detox program or drug rehab program?
If yes (detox), when and where
Parent's marital history
Would you describe your marital relationship as having:
No difficulties
Occasional difficulties
Frequent difficulties
Not currently married
Separation
Have there been separations of your child from either parent?
Father
Yes
No
Dates
Describe including child's reaction:
Mother
Yes
No
Dates:
Describe including child's reaction:
Was either parent unable or unwilling to care for the child at any time?
Yes
No
Describe reason and child's reaction:
Birth
Labor difficulties:
C-Section
Prolonged Labor
Breech birth
Loss of oxygen
Other
Comments:
Weight (lb)
Weight (lb)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Weight (oz)
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Length (inches)
Location:
Comments:
Postnatal
Medical complications:
Jaundice
Infections
Respiratory problems
Need for incubation
Other
Comments:
Feeding:
Breast fed
Bottle fed
Vomitting
Colic
Diarrhea
Food allergies
"Picky" eater
Postpartum depression for mother:
Yes
No
Slept through the night at age (months):
Developmental milestones
Sat unsupported at:
Crawled at:
Walked at:
Talked - first word at:
Two word phrases:
Toilet trained at (age):
Continues to have difficulties:
Yes
No
Wetting:
Day
Night
Soiling:
Day
Night
Toileting comments (frequency of issues, details):
Early development
To whom is the child primarily attached?
Mother
Father
Other
Who else is the child strongly attached to?
Did the child experience a change in caretakers before the age of 3?
Yes
No
Please describe:
How old was the child when they entered daycare/preschool/early intervention or other program?
List specific programs and approximate dates (including full or half-day babysitting):
Name of Program
Date
1
2
3
4
Education
Current school:
Current grade:
Repeated grade:
Yes
No
Grade(s) repeated:
IEP:
None
Learning
Behavior
Learning and behavior
Patient's understanding of special educational services:
Language/cultural issues:
Yes
No
Describe:
Suspensions/expulsions:
Yes
No
Describe:
Transfers:
Yes
No
Describe:
Relationship with teachers:
Relationship with peers:
Strongest subjects:
Average grades:
Parents relationship with school:
Employment history
Patient employed:
Yes
No
Place of employment:
Length of employment:
Number of hours:
Occupation:
Employment history:
Legal problems:
None
Arrests
CHINS
Probation
DYS
Victim/witness
Restraining order
Submit
Should be Empty: