Adult Intake Form
In order for me to be able to fully evaluate you, I request that you fill out the following intake form completely to the best of your ability. I realize that there is a lot of information, but every question is important. Please do the best you can to answer each and every question completely and accurately. Thank you!

*** This practice can not be held liable for information intercepted during the transmission of this form. If you are uncomfortable using this transmission method to complete your history forms, please contact the office for alternative methods of completion. This practice does not provide preferential treatment to patients based on the type of form they choose to complete. ***

Date *
MM
/
DD
/
YYYY
*
Name
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Sex *
Phone Number *
Your answer
E-mail address *
Your answer
Your occupation, age, and highest grade level completed *
Your answer
In your own words, please describe why you are seeking assessment today: *
Your answer
Has the problem affected your work or schooling? *
How much is your daily life impacted by this problem? *
Not at all
A great deal
How has your problem worsened or progressed? *
Your answer
What are the top stressors in your life at this time? *
(i.e. social, work, financial, loss of a loved one, etc)
Your answer
MEDICAL HISTORY *
Have you ever experienced any of the following? (check all that apply)
Required
List your CURRENT medical problems
Your answer
Hospitalizations for illness or accident
(when, where, why, how long, outcome?)
Your answer
MEDICAL HISTORY *
List CURRENT medical problems
Your answer
Medications *
Please list all medications you are currently taking, along with information regarding what disorder they are prescribed to treat, the dosage, how often, what time of day taken, and any side effects that have been noticed. Please include all over-the-counter, herbal, and “nontraditional” medicines. Attach a sheet if necessary.
Your answer
Sleep behavior
check all that apply
What time do you go to bed and get up regularly?
Your answer
Vision and Hearing *
Normal
Corrected
Needs to be checked
Vision
Hearing
Do you exercise? *
How much caffeine do you ingest?
None
1-2 servings per day
3-5 servings per day
6 or more servings per day
Soda
Coffee
Energy drink (e.g. red bull, 12 hr energy)
Other
Do you have a family history of the following?: *
Yes
No
Don't Know
Anxiety
Depression
Manic Depression/Bipolar Disorder
ADHD/ADD
Autism Spectrum Disorder
Learning Disability
Dementia or Alzheimer's
Seizures
Stroke
Other
Psychiatric Diagnoses *
List all diagnoses, dates given, and name/type of professional diagnosing:
Your answer
Other psychiatric information
Has the child...
Yes
No
Have you been prescribed medication for a mental health problem?
Have you been hospitalized for a mental health problem?
Have you had counseling or therapy?
Are you in counseling or therapy currently?
Have you attempted suicide?
Have you been a victim of physical abuse?
Have you been the victim of sexual abuse?
Have you been the victim of emotional abuse?
Have you witnessed extreme violence?
How often do you use alcohol? What type (hard liquor, beer, wine)?
Your answer
How often do you use recreational drugs? What type?
Your answer
Have you ever experienced withdrawal symptoms from drugs or alcohol? *
Your answer
Do you use tobacco products? Which type and how often?
Your answer
DEVELOPMENTAL HISTORY *
Are you aware of any of the following?
Required
How many years of education do you have? Did you graduate from high school? *
Your answer
How would your teachers have described you as a student? *
Your answer
Did you receive special education services or Section 504 accommodations at any time? If so, explain. *
Your answer
Please list your most current job first, then past jobs for the past FIVE years. *
Your answer
Describe your current living situation. *
With whom do you live? Do you have children? Have you been married?
Your answer
Family History: *
Where did you grow up? Did you move frequently? How many siblings do you have?
Your answer
Please include anything else about your case that you think is important for us to include in your report to help decide appropriate actions for your case? *
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service