Intake Form

Contact Information

Patient's Legal Name

Preferred Name

Current Gender Identity

What Sex Were You Assigned At Birth

Male

Female

What pronouns do you prefer that we use when talking about you?

Address

City

State

Zip Code

Home Phone

Ok to leave detailed message?

Yes No

Cell Phone

Ok to leave detailed message?

Yes No

Work Phone

Ok to leave detailed message?

Yes No

Email address

Date of birth

Number of children, gender, ages

Occupation

Current job

Emergency Contact

Name

Phone number

Relationship to you

What name do you want me to use for you if I call your emergency contact?

What pronouns do you want me to use to talk about you if I call your emergency contact?

This information is requested in the event of a psychiatric emergency. No information will be given to anyone about your treatment status or appointments without your expressed permission.

Referral Source

If other, please explain

Working with Your Therapist

What brings you in to work with me?

What is your history with this issue?

What are your goals?

How will you know when you have achieved these goals?

What challenges do you anticipate?

What kind of supports do you have in place?

What are some important things you want me to know about you?

Medical Information

Primary care physician

Phone number

Date of last physical

Have you been diagnosed with any medical conditions? Please list all and date of diagnosis.

Have you ever been diagnosed with any mental health conditions? Please list all and date of diagnosis.

Medications you are currently taking (include reason for taking them, dose, and frequency):

Are you currently taking medications for a mental health issue?

Yes No

If yes, please list name of medication, dose, frequency, and reason you are taking it.

Name of doctor prescribing the medication

If other, please explain

Are you currently taken any supplements, essential oils, or herbal remedies?

Yes No

If yes, please list what you are taking, dose, frequency, and reason you are taking it.

Have you ever been hospitalized for psychiatric reasons?

Yes No

If yes, please list dates, length of hospitalization, and reasons for admission.

Are you currently being treated for any medical conditions?

Yes No

If yes, please list condition, treatment, and impact on your daily functioning.

Other Specialists you see
(ex: PT, OT, alternative medicine, psychiatrist, pain management)

Add additional specialist

Substance Use

Recreational Drugs Use?

Yes No

What are you using? (this includes pills of any kind)

How often?

Are you hiding this from anyone? If so, who?

Who do you use with?

Do you ever use alone? If so, when?

How does drug use help you?

Alcohol Use

Yes No

How many times a week are you drinking?

What do you drink?

Are you hiding this from anyone? If so, who?

Do you ever drink alone? If yes, when?

How does drinking help you?

Patient Safety Screener

Because some topics are hard to bring up, I ask everyone these questions.

Over the past 2 weeks, have you felt down, depressed, or hopeless?

Yes No

Over the past 2 weeks, have you had thoughts of killing yourself?

Yes No

Have you ever attempted to kill yourself?

Yes No

If yes, when did this last happen?

Within the past 24 hours (including today) Within the last month (but not today) Between 1 and 6 months ago More than six months ago

Have you ever tried to take your own life in the past?

Yes No

If yes, when

Is there a history of self harm or suicide in your family?

Yes No

Over the past 2 weeks, have you had thoughts of hurting other people?

Yes No

If yes, please name who

Do you have a history of physically hurting or assaulting other people?

Yes No

If yes, please describe what happened.

High Risk Activities

Please indicate if you’ve ever done any of these activities, how often, and whether it’s happening now or happened in the past.

Driving while drunk/high