Intake form 2

Name:

Relationship:

Phone number:

Email:

Referral Information:

Were you referred?

Yes

No

If referred, by whom?

Payment Information:

Please indicate how you intend to pay for treatment:

Credit Card

Venmo

Insurace

Clear selection

Previous Mental Health Treatment History:

Have you participated in therapy?

Yes

No

Clear selection

If YES, please complete the information below:

Name

If YES, please complete the information below:

Name

Type of Provider (Psychiatrist, Psychologist, Therapist, or
Other)

Phone Number

Email

Street Address

City

State

Dates of treatment

Focus of treatment

If YES, please complete the information below:

Name

Type of Provider (Psychiatrist, Psychologist, Therapist, or
Other)

Phone Number

Email

Street Address

City

State

Dates of treatment

Focus of treatment

Have you ever been hospitalized because of a mental health disorder, yes or no?

Yes

No

Clear selection

Reason for hospitalization

Was hospitalization voluntary or involuntary? Please check:

Voluntary

Involuntary

How long was your hospitalization?

Where were you hospitalized?

Course of treatment during hospitalization:

Provide the name of the providers who treated you below. Please indicate the type of provider
(i.e., Psychiatrist, Psychologist, MD, Licensed Therapist)

Name

Type of Provider (Psychiatrist, Psychologist, Therapist, or
Other)

Phone Number

Email

Street Address

City

State

Dates of treatment

Current Mental Health Treatment

Are you currently participating in therapy or counseling?

Yes

No

Clear selection

If YES, please
complete the following information

Name of Current Provider:

Type of provider

Phone Number

Email

Street Address

City

State

Dates of Treatment

Focus of Treatment

If you are currently receiving therapeutic services from another psychotherapist, to avoid a
duplication of services, it may be necessary for me to contact your current psychotherapist to
coordinate care. You may be required to sign and “Authorization for Release of Confidential
Information” form which will be provided to you and maintained as part of your clinical record
long with a copy of this patient intake form.* Please Initial

If you are currently under the care of a psychiatrist, are you taking any prescribed psychiatric
medication(s), yes or no? Yes ______ No_____. If you indicated that you are currently taking
psychiatric medication, please list the type of medication, the specific medication you have been
prescribed, the dosage, and any side effects in the space below.

Yes

No

Clear selection

For example: “Antidepressant (type), Zoloft (specific medication), 50mg once daily (dose),
Insomnia (side effect).”

If you are currently under the care of a psychologist, have you participated in any psychological
assessments or tests yes, or no? Yes ____ No _____. If you have participated in psychological
testing, please list the type of test performed, the specific name of the test, and the date(s) the
test(s) were administered.

Yes

No

Clear selection

For example: “Personality Test (Type), Minnesota Multiphasic Personality Inventory “MMPI-
2” (Specific name of test), February 01, 2017 (Date test was administered).”

California Civil Code Section, 56.10 states that information may be disclosed to “providers of
health care or other health care professionals or facilities for purposes of diagnosis or treatment
of the patient” without the patient’s consent. By initialing, you acknowledge and understand that
I may contact either your current or former mental health care and/or medical providers only to
discuss issues relevant to your diagnosis and treatment without your consent. Initial:

Medical Treatment Information:

Are you currently seeking treatment for a serious or chronic non-psychiatric medical condition,
yes or no?

Yes

No

Clear selection

Current medical condition

How long have you had the condition?

Is it a medically treatable condition, yes or no?

Yes

No

Clear selection

If, it is not a medically treatable condition (i.e., palliative care), please describe:

If you are currently taking prescribed medications for the condition please describe the type of medication, indicate how long you have been taking the medication, and any side effects.

For example: “High blood pressure medication (type of medication); 2 years (length of time on medication); Drowsiness (example of a side effect).

Trauma History (Optional):

Have you been – or are you currently being – emotionally, physically, or sexually abused?

Yes

No

Clear selection

If you checked “Yes,” you may use the space
below to describe the underlying circumstances:

Family of Origin Information (Optional):

Were you adopted, yes or no?

Yes

No

Clear selection

If you were adopted, at what age were you adopted?

If you were adopted, do you have a relationship with your birth mother and/or father, yes or no?

Yes

No

Clear selection

Yes: _____ No: _____If yes, please describe the nature of the relationship. For example, explain
how the relationship with your biological parent(s) was established, how old you were at the time
the relationship began, the frequency of contact you had or currently have, and the nature of the
relationship:

If you were adopted, what type of relationship do you/did you have with your adopted parents?

If you were not adopted, what type of relationship do you/did you have with your biological parents?

Are either of your parents (biological or adopted, and/or step parents) deceased? If your parents are deceased, please provided the following information:

Mother/Stepmother has been deceased for _______ days/weeks/months/years.

What was your age at the time of your mother’s/stepmother’s passing?

Father/Stepfather has been deceased for ______ days/weeks/months/years years.

What was your age at the time of your father’s/stepfather’s death?

Indicate the marital status of your parents (biological/adopted). Check all that may apply:

• Currently married to each other for _____ years

• Currently separated for _____ years

• Divorced for ______years

• Mother remarried _____ times

• Father remarried _____ times

• Mother currently single after being separated/divorced for _____ years

• Father currently single after being separated/divorced for _____ years

• Mother is currently involved with someone, yes or no? If yes, for how long?

• Father is currently involved with someone, yes or no? If yes, for how long?

Do you have any biological siblings, adopted siblings, step siblings, or half siblings, yes or no?

Yes

No

Clear selection

If you have any siblings, how many?

In the space provided below, list the name and ages of each of your siblings and briefly describe the nature of your relationship as being “close,” or “not close,” or “estranged,” or any other word that describes the
nature and extent of your relationship with your siblings.

Which of the following statements most resonates with you:

• My parents were present during my entire childhood, yes or no ? Explain

• My parents were present during a part of my childhood, yes or no? Explain

Which of the following describes your childhood family experience:

It was an outstanding home environment

It was a normal home environment

It was a chaotic home environment

Prefer not to answer

If you indicated that your home environment was chaotic, please explain. For example, you may
have witnessed physical/verbal/sexual abuse towards others, or you may have experienced
physical/verbal/sexual abuse from others:

Mental Health/Risk Assessment:

Please identify if you have experienced any of the following and whether this is a past, current,
or reoccurring issue:

Suicidal Thoughts

Past:

Present:

Reoccurring:

Thoughts of wanting to intentionally harm myself:

Past:

Present:

Reoccurring:

Thoughts of wanting to intentionally cause harm to someone else:

Past:

Present:

Reoccurring:

Post-Traumatic Stress:

Past:

Present:

Reoccurring:

If you are currently experiencing any thoughts of either harming yourself or someone else please
answer the following questions: How long have you had these thoughts?

How frequently do you have these thoughts?

Do you have a plan and/or the means to carry out either the threat of harm to yourself or to
someone else, yes or no? If yes, please explain:

Have you ever tried to harm yourself or anyone else in the past, yes or no? If yes, please explain:

Is there anything that would stop, or prevent, you from harming yourself or someone else, yes or
no? Yes: ____ No: ____ If yes, please explain?

If you indicated that there is not anything that would prevent you from harming yourself or
someone else, please identify how likely it is that you might actually harm yourself or someone
else: Imminently likely: ______ OR Not at all likely: ______

Alcohol/Substance Use History (Optional):

Family Alcohol Abuse History: To the best of your knowledge, please indicate which of the
following family member(s) struggles or struggled with alcohol/substance abuse or addiction:

Father:

Mother:

Grandparent(s):

Sibling(s):

Stepparent(s):

Uncle(s)/Aunt(s):

Spouse/Significant Other:

Children:

Please indicate your substance use status:

No history of use:

Actively using alcohol or drugs:

In early full remission:

In early partial remission:

In sustained full remission:

In sustained partial remission:

If you indicated that you have an alcohol/substance abuse or addiction history, please identify the
types of treatment you have participated in, or are currently participating in, and how long you
have been participating in the particular treatment. Outpatient treatment:

Inpatient treatment:

12-Step Program:

Stopped using on my own:

Other Method:

Was the above treatment method effective? Please explain:

Please identify the type(s) of substances you are using, how frequently you use the substance, and how long you have been using the substance, and your frequency of use (i.e., daily, as needed, no regulation of use, etc.)

(1)

Opioid(s):

Classification:

Length of use:

Frequency of use:

(2)

Heroin:

Length of use:

Frequency of use:

(3)

Cigarettes/Tobacco:

Length of use:

Frequency of use:

(4)

Alcohol:

Length of use:

Frequency of use:

(5)

Amphetamines:

Length of use:

Frequency of use:

(6)

Barbiturates:

Length of use:

Frequency of use:

(7)

Cocaine:

Length of use:

Frequency of use:

(8)

Crack:

Length of use:

Frequency of use:

(9)

Hallucinogens:

Length of use:

Frequency of use:

(10)

Inhalants:

Length of use:

Frequency of use:

(11)

Marijuana:

Length of use:

Frequency of use:

(12)

Other:

Length of use:

Frequency of use:

If you have indicated that you have used, or are currently using substances, please indicate what side effects and or consequences you experienced or are experiencing as a result of the use.

Overdose:

Suicidal Impulse:

Depression:

Anxiety:

Blackouts:

Loss of control:

Medical conditions:

Other:

Please use the space provided to describe any other effects or consequences you have experienced:

Spiritual/Cultural History (Optional):

Do you identify with a particular religion, culture, or spiritual practice? If so, please describe:

Do any of the above religious, cultural, or spiritual issues contribute to your current concerns, problems, or issues? If so, please describe:

Additional Information Please let me know in the space provided, of anything that was not addressed in this intake, and anything that you would like me to know about you, your goals, your relationships, or any recent significant life events:

Primary Physician name:

Address:

Phone:

Patient Signature: