Intake & Assessment Questionnaire

Emergency Assistance

If this is an emergency, call:

Psychiatric Emergency Services: 734-936-5900
911

Please fill in the information below and return prior to your first session.

Name

Preferred Name

Parent/Legal Guardian (if under 18)

Address (Street, City, State, Zip)

Preferred Phone

Preferred Email

Please note: Email correspondence is not considered to be a confidential medium of communication unless it is sent through an encrypted portal.

Age

Date of birth

Gender Identity

Sexual Orientation

Preferred Pronouns

She/Her He/Him They/Them Other

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

Please list any children/ages:

Referred By

Emergency Contact

Add another emergency contact

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

Yes No

History:

Have you previously received mental health services?

Yes No

If yes, what is the previous practitioner's name?

Have you previously been prescribed psychiatric medication?

Yes No

If yes, what medications are you currently taking?

General Health and Mental Health Information:

Add new row

How often do you exercise? What types of exercise do you participate in?

Please list any difficulties you experience with your appetite or disordered eating:

Are you experiencing any chronic pain?

Yes No

If yes, please describe:

Have you recently experienced a loss?

Yes No

If yes, please describe:

Are you experiencing overwhelming sadness, grief or depression?

Yes No

If yes, for how long?

Are you experiencing anxiety, panic attacks or have phobias?

Yes No

If yes, for how long?

Have you had any serious thoughts of suicide or homicide?

Yes No

If yes, how long ago?

Did you have any intention of carrying out your thoughts?

What stopped you from carrying out your plan?

Have you ever attempted suicide or homicide?

Yes No

If yes, how long ago?

Are you currently feeling suicidal or homicidal?

Yes No

How intense are these feelings/thoughts?

Have you experienced physical and/or sexual abuse?

Yes No

When?

If yes, by whom?

How often do you consume alcohol?

Daily Weekly Monthly Infrequently Never

How often do you engage in recreational drug use?

Daily Weekly Monthly Infrequently Never

Are you currently in a romantic relationship?

Yes No

If yes, for how long?

On a scale of 1-10, how would you rate your relationship?

What significant life changes or stressful events have you experienced recently?

Family History:

Place of birth?

Cultural Identity:

Are you adopted?

Yes No

Do you have any siblings?

Yes No

Please list names and ages:

Please list any family members with a history of mental health concerns and/or substance use disorder:

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

Additional Information:

What is your highest level of education completed?

What is your current employment or education situation?

If not currently working, what was your previous employment?

Do you enjoy your work/school?

Yes No

Is there anything stressful about your current work or school?

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

Regularly Occasionally Never

Do you consider yourself to be spiritual or religious?

Yes No

If yes, please describe:

What do you consider to be some of your strengths?

What do you consider to be some of your weaknesses?

What are some of your coping skills?

Reasons for Visit:

Describe the reasons you are seeking therapy.

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

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

Healing & Wellness Arts, PLLC

455 East Eisenhower Parkway, Suite 300

Ann Arbor, MI 48108

Your information will be encrypted.