Connect Psych Network, Intake Form (Adult)

Before filling out this intake form, Please Read

This intake form is not for emergencies or crisis situations. If you are experiencing a mental health emergency, please call 911 or the Suicide & Crisis Lifeline at 988 immediately.

Suicide Prevention Lifeline Call 1-800-273-8255
911

Client Information

First name

Last name

Date of birth

Contact Information

Phone number

Email address

Address

Zip Code

City

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 permission to contact this person?

Yes No

Medical History

Have you been diagnosed with any mental health conditions in the past? If yes, please specify.

Have you previously seen a psychiatrist for mental health treatment? If yes, please provide their name.

Have you been prescribed psychiatric medication in the past? If yes, are you currently taking any? If so, please list them.

Are there any other medical conditions, allergies, or past hospitalizations relevant to your care?

Are you currently pregnant or planning to become pregnant?

Yes No N/A 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 relationship (s) you would like us to be aware of?

Do you have any children?

Yes No

Do you have a family history of psychiatric conditions, mental health disorders, suicide, or self-harm? If yes, please specify.

(For example, depression, anxiety, bipolar disorder, schizophrenia, ADHD, or substance use disorders.)

Does anyone in your family have a history of substance use problems or addiction?

If yes (Please specify the family member’s relationship.)

Personal History

What is your highest level of education?

Are you currently employed?

Yes No

Do you use any substances, including cannabis, nicotine, or other drugs?

If yes, please specify which substances and how often.

Do you use cigarettes or other nicotine products?

Regularly Occasionally No

Do you drink alcohol?

Regularly Occasionally No

Do you engage in gambling activities (e.g., casino games, sports betting, lottery)? If yes, how often?

Regularly Occasionally No

How often do you get a full night’s sleep (7–9 hours)?

Regularly Occasionally Never

"How often do you engage in physical exercise?

Regularly Occasionally No

How often do you engage in recreational or leisure activities (hobbies, socializing, entertainment)?

Regularly Occasionally Never

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

Reasons for Visit

What are the main concerns or symptoms that brought you here today?

(Example: anxiety, depression, mood swings, sleep problems, etc.)

What are your goals or expectations from this evaluation or medication management?

(Example: symptom relief, medication adjustment, diagnosis clarification, etc.)

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

Your information will be encrypted.