Mental Health Intake Form

Name *

First

Last

Email *

Phone *

Date of Birth Date *

Gender *

Primary Care Physician *

First

Last

Current Therapist Counselor *

First

Last

Therapist Phone Number *

Please list the problem(s) which you are seeking help?

Current Symptoms *

Have you ever had feelings or thoughts that you didn't want to live? *

Yes
No

Do you currently feel that you don't want to live? *

Yes
No

How often do you have these thoughts?

When was the last time you had thoughts of dying? *

On a scale of 1 to 10, (ten being strongest) how strong is your desire to kill yourself currently? *

1 - Weak	2	3	4	5	6	7	8	9	10 - Strong
1 - WeakDo you feel hopeless and/or worthless? 1 - Weak	2Do you feel hopeless and/or worthless? 2	3Do you feel hopeless and/or worthless? 3	4Do you feel hopeless and/or worthless? 4	5Do you feel hopeless and/or worthless? 5	6Do you feel hopeless and/or worthless? 6	7Do you feel hopeless and/or worthless? 7	8Do you feel hopeless and/or worthless? 8	9Do you feel hopeless and/or worthless? 9	10 - StrongDo you feel hopeless and/or worthless? 10 - Strong

Do you feel hopeless and/or worthless? *

Yes
No

Have you ever tried to kill or harm yourself before? *

Yes
No

Is there anything that would stop you from killing yourself? *

Yes
No

Medical History

Do you have any allergies? (if yes, please list them)

Current Weight *

Current Height *

List all current prescription medications and how often you take them

Medication

Total Daily Dosage

Estimated Start Date

Current medical problems *

Past medical problems, nonpsychiatric hospitalization, or surgeries *

For women only:

Date of last menstrual period

Are you currently pregnant or do you think you might be pregnant?

Yes
No

Are you planning to get pregnant in the near future?

Yes
No

Birth control method

How many times have you been pregnant?

How many live births?

PSYCHIATRIC HISTORY:

Outpatient treatment *

Yes
No

Psychiatric Hospitalization *

Yes
No

to Name: Current

FAMILY PSYCHIATRIC HISTORY

Has anyone in your family been diagnosed with or treated for: *

Other family diagnosed:

Has any family member been treated with a psychiatric medication? If yes, who was treated, what medications did they take, and how effective was the treatment?

EXERCISE LEVEL

Do you exercise regularly?

Yes
No

How much time each day do you exercise?

Check if you have ever tried the following: *

Tired other:

How many caffeinated beverages do you drink a day?

TOBACCO HISTORY

Have you ever smoked cigarettes?

Yes
No

FAMILY BACKGROUND AND CHILDHOOD HISTORY:

Were you adopted?

Yes
No

Where did you grow up?

List your siblings and their ages:

Name:

Age:

Did your parents divorce?

Yes
No

Do you have a history of being abused emotionally, sexually, physically or by neglect? If yes, please mention the details if you feel comfortable doing it or just answer YES or NO.

PERSONAL HISTORY

Highest grade completed?

Are you currently:

Are you currently

Do you have any children?

Yes
No

Have you ever been arrested?

Yes
No

Additional information:

Emergency Contact *

First

Last

Emergency Contact Phone

Signature *

Clear Signature

Guardian Signature (if under age 18)

Clear Signature

Today's Date

Pyschosocial Rehabilitation Program (PSR)

Please list the problem(s) which you are seeking help?

Medical History

Do you have any allergies? (if yes, please list them)

List all current prescription medications and how often you take them

For women only:

PSYCHIATRIC HISTORY:

FAMILY PSYCHIATRIC HISTORY

EXERCISE LEVEL

TOBACCO HISTORY

FAMILY BACKGROUND AND CHILDHOOD HISTORY:

List your siblings and their ages:

PERSONAL HISTORY

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336-395-3057

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