MAMHC INTAKE
Please complete the following to the best of your abilities. Use N/A were appropriate.
Name (First Last) *
Full Physical Address (Number/Street/City/State/Zip) *
Phone *
Email *
Emergency contact (Name and phone number) *
Do you give consent to contact your emergency contact in a case of addressing your care or crisis? (If you do not consent to this person, then put someone you would consent to.) Enter their name in this form (cut and paste link into a new webpage): https://docs.google.com/forms/d/e/1FAIpQLSdNd0dQZrcei4MRUiqSRQNRk6AqJRIX354J63H6YCMpZ1TqLw/viewform?usp=sf_link *
Your Date of Birth *
MM
/
DD
/
YYYY
Your Age? *
Primary Care Doctor (Practice and phone number) *
Gender (What you identify as) *
Marital Status *
Do you have children? If so, how many? *
Referred by *
Are you receiving psychiatric services, professional counseling, or psychotherapy elsewhere? *
Have you had previous therapy *
What psychiatric medication are you currently on? *
What psychiatric medication have you been on? *
How is your physical health at the present moment? *
Please list any physical illness that you have or have had. *
Please list recent stressors. *
Please describe any issues with sleep *
Required
How much do you exercise? *
Are you having any issues with eating *
Please list your family history with physical health conditions *
If you have any allergies, please list.... (NA, if not) *
Are you left-handed or right-handed dominant? *
Please identify if you have siblings and where you fall in the order. *
What symptoms are you experiencing? *
Yes
No
Currently
Within past month
Within past year
Stomach aches
Migraines
Sweating
Increased heart rate
Loss of appetite
Vision issues
Fatigue
Weakness
Over active
Disorientation
Hearing issues
Smelling issues
Balance issues
Memory issues
Thyroid
Asthma
Allergies
Earaches
Teeth grinding
Nausea
Irritable bowel
Fainting
Seizures
Headaches
Speech Issues
Coordination issues
Chronic Nerve pain
Chronic aching pain
Muscle cramps
Accident Prone
Tremors or Spasticity
Impulsivity
Hyperactivity
Distractibility
Sense of direction issues
Sexual interest
Sexual dysfunction
PMS symptoms
Menopausal symptoms
Incontinence
Sexually Transmitted Disease
Vertigo
Narcolepsy
Do you have a history of Traumatic Brain Injury (TBI)? Or history with concussions? *
What is the state of your mental health currently? *
In the last year, have you experienced any significant life changes or stressors? *
If so, please list *
What symptoms are you experiencing? *
Yes
No
Currently
Within past month
Within past year
Reoccurring dreams
Panic
Anxiety
Unexplained losses of time
Hallucinations
Mania
Eating Disorder
Obsessive-compulsive
Intrusive images, thoughts, feelings
Depression
Mood swings
Phobias
Self-Harm
Body Complaints
Repetitive behaviors
Suicidal Ideation
Homicidal ideation
Have you had suicidal thoughts recently? *
Have you had suicidal thoughts in the past? *
Any history with mania? *
What is your family history with psychological health? (Please identify relatives medical history i.e., diagnoses and diseases) *
Do you do anything to excess? i.e., Worry, Shopping, Sex, Working out, Working, *
Do you regularly use alcohol? If so, how much and how often? *
Do you regularly use illicit substance? If so, what, how much and how often? *
Do you have any driving under the influence offenses? If yes, please state how many. If no, write no. *
Do you tobacco products? If so, what, how much and how often? *
Do you gamble? If so, how much and how often? *
Do you have access/own a gun or a permit to carry a concealed weapon? *
Are you currently in a relationship? *
If so, how long have you been in this relationship? *
If so, rate the quality of the relationship 0-10 (0 being poor and 10 being excellent) *