Adult Intake Form

Patient Information

Name(Required)

First

Last

Date of Birth(Required)

Phone(Required)

Email(Required)

Mailing Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Expected location when participating in sessions

Identified Gender

Preferred Language

Marital Status

Employment

Do you have any children?

Yes

No

If yes, how many?

How did you hear about HealthLinkNow?

Insurance Information

Social Security Number(Required)

Primary Insurance

Primary Member/Subscriber ID

Secondary Insurance

Secondary Member/Subscriber ID

Psychiatric History

Are you currently prescribed medications for your mental health?

Yes

No

Current Medications

Please add one row for each medication, additional rows can be added by clicking the plus (+) icon at the end of last row.

Name of Medication

Prescribed by Psychiatrist or Primary Care Physician? (Please choose either Psych or PCP)

Date of Prescription

Have you been prescribed medications for your mental health in the past?

Yes

No

Past Medications

Please add one row for each medication, additional rows can be added by clicking the plus (+) icon at the end of last row.

Name of Medication

Prescribed by Psychiatrist or Primary Care Physician? (Please choose either Psych or PCP)

Date of Prescription

Have you ever been psychiatrically hospitalized?

Yes

No

Hospitalization Details

Please add one row for each hospitalization, additional rows can be added by clicking the plus (+) icon at the end of last row.

Voluntary/Involuntary?

Length of Stay

Dates

Name of Facility

Have you ever self-harmed?

Yes

No

Examples include (but not limited to) cutting, scratching, burning, punching,

Please describe

Mental Health History

Reason for seeking mental health treatment

Have you experienced any recent life changes or stressful events?

What are your treatment expectations? What goals to you hope to achieve through treatment?

Have you ever participated in mental health treatment (psychotherapy, psychiatric services, counseling, etc)?

Yes

No

Past Mental Health Treatment

Please add one row for each past treatment, additional rows can be added by clicking the plus (+) icon at the end of last row.

Dates of Treatment

Treatment Provider

Reasons for Treatment

Substance Use History

Do you use alcohol?

Yes

No

How many days per week do you drink?

How many drinks typically consumed in that day?

Do you use nicotine/marijuana?

Yes

No

How frequently do you use nicotine/marijuana?

Do you use any other substances?

Yes

No

Additional Substances Used

Please add one row for each substance, additional rows can be added by clicking the plus (+) icon at the end of last row.

Substance

Frequency/Amount of Use

Family History

Have any of your family members been diagnosed with a mental illness, addiction or been treated by a mental health professional?

Yes

No

Additional Details for Family History

Please add one row for each family member, additional rows can be added by clicking the plus (+) icon at the end of last row.

Relationship of Family Member

Diagnosis or Reason for Treatment

Social History

What is your employment/education status?

Please describe any involvement with law enforcement and any legal matters within the past 12 months

Medical History

Do you have an Advanced Directive?

Yes

No

Primary Care Provider (PCP) Name

PCP Address

Street Address

Address Line 2

City

State

PCP Phone

PCP Fax

Date of last PCP physical exam

Current medical issues/problems

Current Physical Pain Level

Weight Change during past 3 months

gain/loss of 10 or more pounds

Allergies to food or medications

Please add one row for each food/medication, additional rows can be added by clicking the (+) icon at the end of last row.

Medications taken currently

Please add one row for each food/medication, additional rows can be added by clicking the plus (+) icon at the end of last row.

Medication

Dosage/Frequency

Prescribed by Psychiatrist or Primary Care Physician?

Date of Prescription

Patient Health Questionnaire (PHQ-9)

Over the last week, how often have you been othered by the following problems?

Little Interest or pleasure in doing things

Feeling down, depressed, or hopeless

Trouble falling or staying asleep, or sleeping too much

Feeling tired or having little energy

Poor appetite or overeating

Feeling bad about yourself – or that you are a failure or have let yourself or your family down

Trouble concentrating on things, such as reading the newspaper or watching television

Moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual

Thoughts that you would be better off dead or of hurting yourself in some way

If ANY of these problems have affected you, how difficult have the problems made it for you to do your work, take care of things at home, or get along with other people?

Email

This field is for validation purposes and should be left unchanged.

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