New Patient Intake Form (Adult)

Emergency Assistance

If this is an emergency, call:

Client Information

First name

Last name

Date of birth

Gender

Preferred Pronouns

Contact Information

Phone number

Email address

Address

City

State

Zip Code

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

Yes No

If no, what is your preferred method of communication?

Name of Health Insurance

Health Insurance ID#

Health Insurance Contact Telephone Number

Name of Primary Insured

Emergency Contact

Add another emergency contact

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

Yes No

Reasons for Visit

Describe the reasons you are seeking an appointment.

Are you having thoughts to harm yourself or others?

Yes

*IF YOU ARE FEELING UNSAFE, PLEASE SEEK EMERGENCY CARE BY CALLING 911 OR GOING TO YOUR CLOSEST HOSPITAL EMERGENCY DEPARTMENT*

Do you have any history of self-harm or suicide attempt?

Yes No

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

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

Medical and Psychiatric History

Have you previously had outpatient mental health treatment?

Yes No

If yes, with whom and when?

Have you ever been hospitalized for mental health treatment?

Yes No

If yes, where and when?

Have you previously been prescribed psychiatric medication?

Yes No

If yes, what medications are you currently taking?

What other psychiatric medications have you taken in the past?

Do you have any pre-existing medical conditions?

What is the name of your Primary Medical Care Provider?

What is your preferred pharmacy?

Are you pregnant?

Yes No Not sure Not applicable

If yes, how far along?

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

Family History

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

How often do you get a full night of sleep?

Regularly Occasionally Never

Do you have a healthy and balanced diet?

Regularly Occasionally No

Do you exercise?

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?

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