Better Days and Nights PLLC

Telephone: 828.333.4170

Better Days and Nights PLLC Secure Client Intake Form

Please fill out all the questions you can. Some boxes/questions are required and have and asterisk next to them. If you can not answer a required question please fill it with XXXXX's or 00000's. Thank you

Client Information

Full Name

Nick or Preferred Name

Date of Birth

Age

Name of parent/guardian (if under 18 years):

Male

Female

Other

If other please indicate gender

Home Phone or Cell

OK to leave you a message

Cell Phone

Ok to leave you a message

Ok to text you?

Email address *

*Please note:
Email or text correspondence is not considered to be a confidential medium of communication.

Street Address

Referred by (if any):

Subscriber ID/Member Number or Policy Number:

Name of Policy Holder:

Address of Insured (will not contact, for insurance purposes only):

Assignment of insurance benefits:
I hereby authorize direct payment of Mental Health benefits to the Therapist or to whomever he/she designates, and I also authorize direct payment of all other benefits to Better Days and Nights and its subsidiaries. The benefits referred to herein would be payable to me if I did not make assignment and include major medical insurance. I understand to my satisfaction that I am personally responsible to the Practice and Therapist respectively for charges not covered by this agreement. I agree to pay out-of-pocket for sessions lasting more than 60 minutes at the rate of $100.00 per hour broken down in to 15-minute segments of $25.00. I also authorize Better Days and Nights and my attending Therapist to release any medical information required in processing of applications for final insurance coverage for services rendered.

Please check if you do have insurance and agree.

Emergency Contact:

Name

Relationship to the client

Home Phone

Ok to leave message

Cell Phone

Ok to leave message

Ok to text

Are you currently employed?

Yes

If yes, what is your current employment situation: Please provide employment title and employer information

Do you enjoy your work? Is there anything stressful about your current work?

Do you consider yourself to be spiritual or religious? If yes, describe your faith or belief:

Yes

Religious description

What do you consider to be some of your strengths?

What do you consider to be some of your weaknesses?

What would you like to accomplish out of your time in therapy?

Mental Health Status:

Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?

Yes

If Yes, please state the therapist/psychologist/counselor/psychiatrist's name.

Are you currently taking any prescription medication or have you ever been prescribed psychiatric medication?

Yes

If yes please list all Medications

Are you currently experiencing overwhelming sadness, grief or depression?

Yes

If yes for approximately how long?

Are you currently experiencing anxiety, panic attacks or have any phobias?

Yes

If yes, please describe them and when you began experiencing them?

Are you currently experiencing any chronic pain?

Yes

If yes, please describe

What significant life changes or stressful events have you experienced recently?

Relational Status:

Present Status

Single Never Married Domestic Partnership Married Separated Divorced Widowed In a long term relationship

Are you currently in a romantic relationship?

Yes

If Yes how long?

On a scale of 1-10, how would you rate your relationship?

Please list any children/age

General Health Information:

How would you rate your current physical health?

Poor Unsatisfactory Satisfactory Good Very Good

Please list any specific health problems you are currently experiencing:

How would you rate your current sleeping habits?

Poor Unsatisfactory Satisfactory Good Very good

Please list any specific sleep problems you are currently experiencing:

How many times per week do you generally exercise?

What types of exercise to you participate in?

Please list any difficulties you experience with your appetite or eating patterns

Do you drink alcohol more than once a week?

Yes

If yes how often

How often do you engage in recreational drug use?

Daily Weekly Monthly Infrequently Never

FAMILY MENTAL HEALTH HISTORY:

In the section below identify if there is a family history of any of the following. If yes, please indicate the family member’s (father, grandmother, uncle, etc.) next to each.

Alcohol/Substance Abuse

Family Member/s

Anxiety

Family Member/s

Depression

Family Member/s

Domestic Violence

Family Member/s

Eating Disorders

Family Member/s

Obesity

Family Member/s

Obsessive Compulsive Behavior

Family Member/s

Schizophrenia

Family Member/s

Suicide Attempts

Family Member/s

Please describe any additional information that may help us understand your situation or concerns.

Signing below you agree that your Better Days and Nights therapist and or office employees can contact you or your Emergency Contact via phone, email or text as check above.

Digital Signature (type your name)

Date of Signature

DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure—Adult

Instructions: The questions below ask about things that might have bothered you. For each question, choose numbers 0 - 4 that best describes how much (or how often) you have been bothered by each problem during the past TWO (2) WEEKS.

Item 0 None at all
Item 1 Slight or Rare, Less than one day or two
Item 2 Mild Several Days
Item 3 Moderate more than half the days
Item 4 Severe nearly every day

I

1. Little interest or pleasure in doing things?

Number field

2. Feeling down, depressed, or hopeless?

Number field

II

3. Feeling more irritated, grouchy, or angry than usual?

Number field

III

4. Sleeping less than usual, but still have a lot of energy?

Number field

5. Starting lots more projects than usual or doing more risky things than usual?

Number field

IV

6. Feeling nervous, anxious, frightened, worried, or on edge?

Number field

7. Feeling panic or being frightened?

Number field

8. Avoiding situations that make you anxious?

Number field

V

9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)?

Number field

10. Feeling that your illnesses are not being taken seriously enough?

Number field

VI

11. Thoughts of actually hurting yourself?

Number field

VII

12. Hearing things other people couldn't hear, such as voices even when no one was around?

Number field

13. Feeling that someone could hear your thoughts, or that you could hear what another person was thinking?

Number field

VIII

14. Problems with sleep that affected your sleep quality over all?

Number field

IX

15. Problems with memory (e.g., learning new information) or with location (e.g., finding your way home)?

Number field

X

16. Unpleasant thoughts, urges, or images that repeatedly enter your mind?

Number field

17. Feeling driven to perform certain behaviors or mental acts over and over again?

Number field

XI

18. Feeling detached or distant from yourself, your body, your physical surroundings, or your memories?

Number field

XII

19. Not knowing who you really are or what you want out of life?

Number field

20. Not feeling close to other people or enjoying your relationships with them?

Number field

XIII

21. Drinking at least 4 drinks of any kind of alcohol in a single day?

Number field

22. Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco?

Number field

23. Using any of the following medicines ON YOUR OWN, that is, without a doctor’s prescription, in greater amounts or longer than prescribed [e.g., painkillers (like Vicodin), stimulants (like Ritalin or Adderall), sedatives or tranquilizers (like sleeping pills or Valium), or drugs like marijuana, cocaine or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)?

Number field

Thank you for your time, please click send below.

Short text field

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