Adult Registration Intake Form

Mental Health Intake

Please complete this form to the best of your ability.

Please complete all information on this form and bring it to your first visit. It may seem long, but most of the questions require only a check, so it will go quickly. You may need to ask family members about the family history.

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Date Of Birth (day/month/year)

Do you give permission for ongoing regular updates to be provided to your primary care physician?

Yes

Emergency Contact Person

Phone number for emergency contact person

Name of Current Therapist/Counselor

Counselor's Phone Number

What are the problem(s) for which you are seeking help?

What are your treatment goals?

Current Symptoms Checklist: (check any and all symptoms currently present)

Depressed mood

Racing thoughts

Excessive worry

Unable to enjoy activities

Impulsivity

Anxiety attacks

Sleep pattern disturbance

Increase risky behavior

Avoidance

Loss of interest

Increased libido

Hallucinations

Concentration/forgetfulness

Decrease need for sleep

Suspiciousness

Change in appetite

Excessive energy

Excessive guilt

Increased irritability

Fatigue

Crying spells

Decreased libido

Suicide Risk Assessment

Do you currently feel that you don't want to live?

Yes

How often do you have these thoughts?

When was the last time you had thoughts of dying?

Has anything happened recently to make you feel this way?

On a scale of 1 to 10, (ten being strongest) how strong is your desire to kill yourself currently?

Would anything make it better?

Have you ever thought about how you would kill yourself?

Yes

Is the method you would use readily available?

Yes

Have you planned a time for this?

Yes

Is there anything that would stop you from killing yourself?

Do you feel hopeless and/or worthless?

Yes

Have you ever tried to kill or harm yourself before?

Yes

Do you have access to guns? If yes please explain.

Past Medical History:

Allergies

Current Weight

Your Height

List ALL current prescription medications and how often you take them: (if none, write none) Example: List Medication Name | Total Daily Dosage | Estimated Start Date

Current over-the-counter medications, vitamins or supplements

Current medical problems:

Past medical problems and nonpsychiatric hospitalization, or surgeries:

Have you ever had an EKG?

Yes

If had an EKG note when you had it and indicate if normal, abnormal, or you don't know the result.

Women Only

Date of last menstrual period

Birth control method

Are you currently pregnant or do you think you might be pregnant?

Yes

Are you planning to get pregnant in the near future?

Yes

How many times have you been pregnant?

How many live births?

Date and place of last physical exam:

Do you have any concerns about your physical health that you would like to discuss with us?

Personal and Family Medical History:

You may need to ask family members

Check all that apply to you

Thyroid Disease

Anemia

Liver Disease

Chronic Fatigue

Kidney Disease

Diabetes

Asthma/respiratory problems

Stomach or intestinal problems

Cancer

Fibromyalgia

Heart Disease

Epilepsy or seizures

Chronic Pain

High Cholesterol

High blood pressure

Head trauma

Liver problems

Add any other conditions not noted above that apply to YOU?

Check ALL that apply to a FAMILY MEMBER

Thyroid Disease

Anemia

Liver Disease

Chronic Fatigue

Kidney Disease

Diabetes

Asthma/respiratory problems

Stomach or intestinal problems

Cancer

Fibromyalgia

Heart Disease

Epilepsy or seizures

Chronic Pain

High Cholesterol

High blood pressure

Head trauma

Liver problems

Indicate which family member applies to health conditions above. Example: Heart Disease = Father

Add any other conditions not noted above that apply to your Family?

When your mother was pregnant with you, were there any complications during the pregnancy or birth?

Past Psychiatric History:

Outpatient psychiatric treatment

Yes

If yes, to psychiatric outpatient, then describe when, by whom, and nature of treatment. Example: Reason | Dates Treated |By Whom

Psychiatric hosapitalization treatment

Yes

If yes, to psychiatric hospitalization, then describe for what reason, when this occurred and where. Example: Reason | Date Hospitalized | Where.

Past Psychiatric Medications:

Indicate if you have ever taken any of the following medications.

Antidepressants

Antidepressants - check all that apply

Prozac (fluoxetine)

Zoloft (sertraline)

Luvox (fluvoxamine)

Paxil (paroxetine)

Celexa (citalopram)

Lexapro (escitalopram)

Effexor (venlafaxine)

Cymbalta (duloxetine)

Wellbutrin (bupropion)

Remeron (mirtazapine)

Serzone (nefazodone)

Anafranil (clomipramine)

Pamelor (nortrptyline)

Tofranil (imipramine)

Elavil (amitriptyline)

For the antidepressant medications you selected above, please indicate below the following: Example: Medication Name | Dates | Dosage | Side Effect if any | How helpful they were. (if you can't remember all the details, just write in what you do remember).

Mood Stabilizers - check all that apply

Tegretol (carbamazepine)

Lithium

Depakote (valproate)

Lamictal (lamotrigine)

Tegretol (carbamazepine)

Topamax (topiramate)

For the Mood Stabilizers medications you selected above, please indicate below the following: Example: Medication Name | Dates | Dosage | Side Effect if any | How helpful they were. (if you can't remember all the details, just write in what you do remember).

Antipsychotics/Mood Stabilizers - check all that apply

Seroquel (quetiapine)

Zyprexa (olanzepine)

Geodon (ziprasidone)

Abilify (aripiprazole)

Clozaril (clozapine)

Haldol (haloperidol)

Prolixin (fluphenazine)

Risperdal (risperidone)

For the Antipsychotics/Mood Stabilizers medications you selected above, please indicate below the following: Example: Medication Name | Dates | Dosage | Side Effect if any | How helpful they were. (if you can't remember all the details, just write in what you do remember).

Sedative/Hypnotics - check all that apply

Ambien (zolpidem)

Sonata (zaleplon)

Rozerem (ramelteon)

Restoril (temazepam)

Desyrel (trazodone)

For the Sedative/Hypnotics medications you selected above, please indicate below the following: Example: Medication Name | Dates | Dosage | Side Effect if any | How helpful they were. (if you can't remember all the details, just write in what you do remember).

ADHD medications - check all that apply

Adderall (amphetamine)

Concerta (methylphenidate)

Ritalin (methylphenidate)

Strattera (atomoxetine)

For the ADHD medications you selected above, please indicate below the following: Example: Medication Name | Dates | Dosage | Side Effect if any | How helpful they were. (if you can't remember all the details, just write in what you do remember).

Antianxiety medications - check all that apply

Xanax (alprazolam)

Ativan (lorazepam)

Klonopin (clonazepam)

Valium (diazepam)

Tranxene (clorazepate)

Buspar (buspirone)

For the Antianxiety medications you selected above, please indicate below the following: Example: Medication Name | Dates | Dosage | Side Effect if any | How helpful they were. (if you can't remember all the details, just write in what you do remember).

Your Exercise Level

Do you exercise regularly?

Yes

How many days a week do you exercise?

How much time (minute/hours) do you exercise for on the days when you do?

What kinds of exercise do you do?

Family Psychiatric History:

Has anyone in your family been diagnosed with or treated for any of the following - check all that apply.

Bipolar disorder

Schizophrenia

Depression

Post-traumatic stress

Anxiety

Alcohol abuse

Anger

Other substance abuse

Suicide

Violence

For family psychiatric issues noted, indicate who (father, sister etc.) had which problem?

Substance Use:

Have you ever been treated for alcohol or drug use or abuse?

Yes

If you have been treated for substance abuse indicate for which substances | where treated | when treated.

How many days per week do you drink any alcohol?

What is the least number of drinks you will drink in a day?

What is the most number of drinks you will drink in a day?

In the past three months, what is the largest amount of alcoholic drinks you have consumed in one day?

Have you ever felt you ought to cut down on your drinking or drug use?

Have people annoyed you by criticizing your drinking or drug use?

Have you ever felt bad or guilty about your drinking or drug use?

Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?

Do you think you may have a problem with alcohol or drug use?

Have you used any street drugs in the past 3 months? If yes, which ones?

Have you ever abused prescription medication? If yes, which one and for how long?

Check if you have ever tried the following:

Methamphetamine

Cocaine

Stimulants (pills)

Heroin

LSD or Hallucinogens

Marijuana

Pain killers (not as prescribed)

Methadone

Tranquilizer/sleeping pills

Alcohol

Ecstasy

If you did try substances, indicate | Name | For how long | When did you last use?

How many caffeinated Coffee's do you drink a day?

How many caffeinated Tea's do you drink a day?

How many caffeinated Soda's do you drink a day?

How you ever smoked cigarettes?

Yes

If you currently smoke - How many packs per day on average? And for how many years?

If you smoked in the past - How many years did you smoke? And when did you quit?

Do you now or did you in the past smoke

Pipe

Cigars

Chewing Tobacco

Pipe, Cigar or Chewing Tobacco - What kind? How often per day on average? How many years?

Family Background and Childhood History:

Were you adopted?

Yes

Where did you grow up?

List your siblings and their ages

What was your father's occupation?

What was your mother's occupation?

Did your parents' divorce?

Yes

If your parents did divorce, how old were you when they divorced?

If your parents divorced, who did you live with?

Describe your father and your relationship with him

Describe your mother and your relationship with her

How old were you when you left home?

If anyone in your immediate family died, indicate who and when died.

If you have a history of being abused emotionally, sexually, physically or by neglect - Please describe when, where and by whom:

Education & Occupational History:

Highest Grade Completed and Where?

What is your highest educational level or degree attained?

Did you attend college? If so where? And what was your major?

Are you currently:

Working

Student

Unemployed

Disabled

Retired

If you are employed where do you work?

What is/was your occupation and how long in that position?

Have you ever served in the military?

Yes

If you ever served in the military? If so, what branch and when? Indicate if you have been discharged - honorable or otherwise.

Relationship History and Current Family:

Your current relationship status - select

How long in your current relationship status

Are you sexually active?

Yes

How would you identify your sexual orientation?

What is your spouse or significant other's occupation?

If you had any prior marriages, indicate how many and for how long

Describe your relationship with your spouse or significant other:

Do you have children?

Yes

If have children, list ages and gender:

Describe your relationship with your children

List everyone who currently lives with you

Legal history:

Have you ever been arrested?

Yes

Do you have any pending legal problems?

Yes

Describe any legal issues you are having, if any.

Spiritual History:

If you belong to a particular religion or spiritual group - what is your level of your involvement?

Do you find your spiritual involvement helpful during this illness, or does the involvement make things more difficult or stressful for you?

Is there anything else that you would like us to know?

Signature

Sign Here

Today's date (day/month/year)

Guardian Signature (if under age 18)