Behavioral Health Intake

Name:

Date:

PRESENTING PROBLEMS AND CONCERNS

Describe the problem that brought you here today:

What are the goals and objectives that you want from your treatment?

Other:

Strengths, Needs, Abilities, Preferences & Liabilities

Please describe your perceptions concerning your personal strengths, needs, abilities & preferences as you relate them to your overall functioning in the community. Include any liabilities in these areas that need to be addressed in your treatment, as well as preferences for treatment.

Strengths:

Needs:

Abilities:

Preferences:

Liabilities:

Leisure or Community Activities and Personal Interests

If yes, please describe these and any other personal interests:

If yes, please describe

FAMILY AND DEVELOPMENT HISTORY

Mother

Name:

Age:

Quality of Relationship

Supportive Relationship

Father

Name:

Age:

Quality of Relationship

Supportive Relationship

Stepmother

Name:

Age:

Quality of Relationship

Supportive Relationship

Stepfather

Name:

Age:

Quality of Relationship

Supportive Relationship

Siblings

Name:

Age:

Quality of Relationship

Supportive Relationship

Spouse/partner

Name:

Age:

Quality of Relationship

Supportive Relationship

Children

Name:

Age:

Quality of Relationship

Supportive Relationship

Family and Development History

Family Mental Health Problems

Hyperactivity

Sexually abused

Depression

Manic Depression

Suicide

Anxiety

Panic Attacks

Obsessive compulsive

Anger-Abusive

Schizophrenia

Eating Disorder

Alcohol Abuse

Drug Abuse

How do you perceive the quality of your relationship with your significant other?

Who are your supports?

Parents legally married or living together

Mother remarried:

Number of times:

Parents temporarily separated

Father remarried:

Number of times:

Parents divorced or permanently separated

If yes, please indicate if the traumatic event was experienced or witnessed and what was the date of trauma:

If you answered yes to any of the above, please describe:

If yes, when and where

If so, please describe:

If yes, when and where_

If yes, please describe the type of abuse, if reported and if so, to whom and the date of the abuse:

PREVIOUS MENTAL HEALTH TREATMENT

Outpatient Counseling

Yes No

When

Provider/Program

Reason for Treatment

Medication (Mental Health)

Yes No

When

Provider/Program

Reason for Treatment

Psychiatric Hospitalization

Yes No

When

Provider/Program

Reason for Treatment

Drug/Alcohol Treatment

Yes No

When

Provider/Program

Reason for Treatment

SUBSTANCE USE HISTORY

Frequency

Amount

Method of Use

Frequency

Amount

Method of Use

Frequency

Amount

Method of Use

Frequency

Amount

Method of Use

Frequency

Amount

Method of Use

Frequency

Amount

Method of Use

Frequency

Amount

Method of Use

Frequency

Amount

Method of Use

Frequency

Amount

Method of Use

Frequency

Amount

Method of Use

Frequency

Amount

Method of Use

Frequency

Amount

Method of Use

Frequency

Amount

Method of Use

If yes, please describe

MEDICAL INFORMATION

Date of last physical exam:

Please list any CURRENT health concerns:

Current prescription medications:

Medication

Dosage

Date First Prescribed

Prescribed By

Add new medications

Current over-the-counter medications (including vitamins, supplements, herbal remedies, etc…)

Allergies and/or adverse reactions to medication:

INTERPERSONAL/SOCIAL/CULTURAL INFORMATION

Please describe your social support network (check all that apply):

Family

Friends

Support/ Self-Help Group

Community Group

Neighbors

Religious Group

Students

Co-Workers

Other

To Which cultural or ethnic group do you belong?

If you are experiencing any difficulties due to cultural or ethnic issues, please describe:

Spiritual Beliefs

Religious Affiliations:

None

If yes, please describe:

MISCELLANEOUS INFORMATION

Employment

Employer:

Position:

Length of time in this position:

Job Duties:

Education

Last Grade Completed:

High School Graduate

GED

Year:

Associate’s Degree

Year:

Area of Study

Undergraduate Degree

Year:

Area of Study

Undergraduate Degree

Year:

Area of Study

Military Service

Have you been/are you currently in the military? (If no, skip remainder of this section)

Branch:

Date of Discharge:

Type of Discharge:

Were you in Combat:

Additional information you feel is important to your care.

Legal

Please explain

DHS Case

OJA Case

JB-Probation

Parental

Other:

Case Worker Name:

Phone #:

Lawyers Name:

Phone #

Please explain

DHS Case

OJA Case

JB-Probation

Parental

Other:

Case Worker Name:

Phone #:

Lawyers Name:

Phone #

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