Patient Intake Form (Adult)

Boston Psychiatric Alliance - Dr. Jan Urkevic

Boston Psychiatric Alliance

(617) 291-6443

Client Information

First name

Last name

Date of birth

Gender

Contact Information

Phone number

Email address

Address

Can we contact you by phone, email, and voicemail?

Yes No

If no, what is your preferred method of communication?

Emergency Contact

Add another emergency contact

In case of an emergency, do we have permissions to contact this person?

Yes No

Medical History

Have you previously received therapy?

Yes No

If yes, what is the therapist's name?

Have you previously been prescribed psychiatric medication?

Yes No

If yes, what medications are you currently taking?

Do you have any pre-existing medical conditions?

Are you pregnant?

Yes No Not sure

If yes, how far along?

Is there anything else regarding your medical history that we should be aware of?

Family History

Is there anything regarding your relationships you would like us to be aware of?

Do you have any children?

Yes No

If yes, briefly describe your relationship with your children.

Briefly describe your relationships with your parents.

Do you have any siblings?

Yes No

Briefly describe your relationship with your siblings.

Is there anything else regarding your family history that we should be aware of?

Personal History

What is your highest level of education?

Are you currently employed?

Yes No

If yes, what is your current occupation?

Do you use drugs?

Regularly Occasionally No

Do you smoke?

Regularly Occasionally No

Do you drink alcohol?

Regularly Occasionally No

Do you drink caffeine?

Regularly Occasionally No

Do you gamble?

Regularly Occasionally No

How often do you get a full night of sleep?

Regularly Occasionally Never

Do you exercise?

Regularly Occasionally No

Do you have a healthy and balanced diet?

Regularly Occasionally No

How often do you have time for fun and recreational activities?

Regularly Occasionally Never

Is there anything else regarding your personal history that we should be aware of?

Reasons for Visit

Describe the reasons you are seeking therapy.

Describe any goals or outcomes you hope to achieve from therapy.

Describe any significant life changes or stressful events that you have recently experienced.

Is there anything else you'd like to tell us about?

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