New Patient Intake Form

Name

Date of Birth:

Age:

Phone number

Email address

Address:

Emergency Contact Name:

Relationship:

Phone number

REASON FOR VISIT

Please describe your main concerns or goals for today’s visit:

Anxiety

Depression

Stress

Relationship Issues

Medication Refills

Others

MENTAL HEALTH HISTORY

Have you been diagnosed with a mental health condition

Yes

If yes, please list:

Past psychiatric hospitalizations

Yes

If yes, when/where:

Previous therapy or psychiatric care

Yes

If yes, please describe:

CURRENT SYMPTOMS

MEDICAL HISTORY

Current medical conditions:

Past surgeries or hospitalizations:

Allergies:

Primary care provider:

MEDICATIONS

Medication:

Dose:

Reason:

Prescribing Provider:

Medication:

Dose:

Reason:

Prescribing Provider:

Medication:

Dose:

Reason:

Prescribing Provider:

SUBSTANCE USE

Alcohol use:

None

Occasional

Weekly

Daily

Cannabis use:

None

Occasional

Weekly

Daily

Nicotine use:

None

Occasional

Weekly

Daily

Previous substance use treatment

Yes

FAMILY HISTORY

(Select all that apply)

Depression

Bipolar disorder

Substance use disorder

Anxiety

Schizophrenia

Suicide attempts or deaths

Prescribing Provider:

SAFETY & RISK

Thoughts of harming yourself

Yes

If yes, optional details:

Thoughts of harming others

Yes

If yes, optional details:

GOALS FOR TREATMENT

What would you like to accomplish through therapy or psychiatric care?

Your information will be encrypted.