Intake Paperwork

Name

Date of Birth

Address

Phone Number

Email address

Insurance

Please note I do not take state insurance, Medicaid/Medicare.

If your insurance is under another person's name, please list below.

Pharmacy

Are you currently actively suicidal with a plan to follow through with ideation?

Have you ever attempted suicide and if so when and what was the method?

Have you ever been hospitalized for a psychiatric condition?

Do you have a history of non-suicidal self injury such as burning, cutting, hitting self, etc… If so please identify the method and when you last engaged in self-harm.

Do you have a history of trauma?

Yes No

Family history of drug/alcohol abuse/overuse? If so what and who?

Family history of mental health issues/diagnoses? If so what and who?

Has anyone in your family had an attempted suicide? If so, who?

Has anyone in your family has a completed suicide? If so, who?

Do you have a history of drug/alcohol abuse/overuse? Is so what type and when?

Alcohol Use

How many times do you drink a week and how many at each sitting?

Cannabis Use

Do you eat, vape, or smoke cannabis? If so how many times a week and how much at each sitting?

Caffeine Use

Do you drink caffeine every day? Is so how much? What kind?

Nicotine Use

History and current. Vaping, chewing, smoking, dipping, or pouches? How much for how long?

Do you have a history/currently have disordered eating; including restricting, binging, and/or purging? It does not have to be diagnosed.

Do you have any mental health diagnoses? If so, what?

Approximate weight

Height

Please tell me a little bit of why you are interested in seeing a Psychiatric Mental Health Nurse practitioner. What are your goals for treatment?

Please list medications you are currently taking including supplements and birth control devices

Are you in therapy? If so, please list name

Please list your history with therapy.

If you previously saw a psychiatrist or psychiatric nurse practitioner please list

General Practitioner

Past medications

Health issues

Last Blood Draw

Was anything abnormal?

Last Physical

First Day of Last Period

Surgeries, please list.

History of seizures?

If you do please give details.

History of concussion. If so, when? And in what circumstances?

Heart issues? If so, please list. This includes high cholesterol and high blood pressure.

Thyroid issues?

Do you have a history of cancer? If so, what?

Does anyone in your family have heart issues? If so, please list. This includes high cholesterol and high blood pressure.

Does anyone in your family have thyroid issues?

Does anyone in your family have a history of cancer? What kind?

Does anyone in your family have a history of seizures?

Does anyone in your family have a history of stroke?

Allergies to medication/latex/food? What was your reaction?

History of Developmental Delays?

Pronouns you go by: She/her; He/him; They/them, Other?

Do you consider yourself Cis-gender (your gender identity is the sex you were assigned at birth), transgender, non-binary, gender-fluid, agender, genderqueer, gender non-forming, or any other presentation of gender?

Did you appear female or male at birth?

Occupation

Highest Level of Education

Are you currently attending college? Where and what is your major?

Religion or spirituality you follow?

Are there any cultural practices or beliefs that I should be aware of to better support you?

Are you a veteran?

Yes No

Do you live alone or with other people? If with other people, who do you live with?

Do you have any children? If so, can you list genders, names, and ages.

Do you have pets? If so, what kind and what are their names?

What is your sexual orientation?

Do you have a special diet?

Do you do anything for exercise? If yes, what kind and how often?

Hobbies

Who are your biggest social supports?

What is your relationship status?

Do you have any concerns for your safety/and or feel unsafe at home? If so, please explain

Do you have a history of assaultive behavior in which you were the perpetrator?

Yes No

Do you have guns in your home? (This question is a recommended suicidal screening question by Kaiser’s suicide training for health care professionals.)

Yes No

If so, are they locked up and do you have access to these guns?

Any legal history?

Please add the name and phone number of your emergency contact.

Who referred you or where did you find my information on the internet?

Upload a Picture of the Front of Your Insurance Card

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Upload a Picture of the Back of Your Insurance Card

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Credit Card #

This form is encrypted and HIPAA compliant. If you do not show for your initial appointment without cancelling first there will be $75 no-show fee. Please email to cancel if you need to do so.

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