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  • Adult Intake Form

Adult Intake Form

Please note: This intake form contains multiple pages, and cannot be saved for later completion. Please include as much information as you have available for each question.

Step 1 of 8 – Patient Info / Insurance

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Patient Information

Name(Required)







Date of Birth(Required)

Mailing Address


















Do you have any children?


Insurance Information

Psychiatric History

Are you currently prescribed medications for your mental health?


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?


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?


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?


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

Mental Health History

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


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?


Do you use nicotine/marijuana?


Do you use any other substances?


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?


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

Medical History

Do you have an Advanced Directive?


PCP Address












Date of last PCP physical exam

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
 

Interest in Treatment

Check all services you are interested in participating in




What topics would you like to address in Group Therapy?










Patient Health Questionnaire (PHQ-9)

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

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







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