Intake Form Individual Intake Questionnaire Full Name Email How did you find our practice? * Friend recommendationDoctor referralGoogle searchProvider directory searchOther What is the reason for seeking psychiatric care? What are your goals for our work together? Do you have, or have you ever had, a problem with self-harm? * YesNo Do you have, or have you ever had, suicidal thoughts? * YesNo, I have never had suicidal thoughts. If yes, when? If yes, how would you end your life? Have you ever attempted suicide? * YesNo, I have never attempted suicide. Please list all attempts and your age when each happened, starting from the most recent event to the oldest event. If yes, when? If yes, how did you do it? Do you have, or have you ever had thoughts or urges to harm someone else or damage their property? * YesNo Is there a history of mental illness in your family? * YesNo Have you ever been hospitalized for a psychiatric issue? * YesNo, I have never been hospitalized for a psychiatric reason. If yes, where? If yes, when did this happen? If yes, why? If yes, length of stay? If yes, diagnosis, if any? If yes, did the hospitalization help you? YesNo On a scale from 0 to 10, how would you rate your sleep? * 012345678910 How many hours of sleep do you typically get? * Do you feel rested upon waking? * YesNo Do you sleep continuously or do you toss and turn? * ContinuouslyToss and turn How often do you wake up in your sleep? If you wake up in your sleep, how long before you fall back asleep? What do you like to do for fun or enjoyment? Do you have any hobbies that you enjoy regularly? Do you prefer your enjoyment alone, with others, or both? * Who do you know that you would consider your closest sources of support or your "inner circle"? Describe your current living situation. Do you live alone, with others, with family, etc.? Is there a reason for your particular living situation? * If you are in a relationship, please describe the nature of the relationship and months or years together. What is your current occupation? What do you do? How long have you been doing it? * What is your level of education? What is your highest degree and type of degree? * Please check any of the following you have experienced in the past six months: Increased appetiteDecreased appetiteTrouble concentratingDifficulty sleepingExcessive sleepLow motivationIsolation from othersFatigue/low energyLow self-esteemDepressed moodTearful or crying spellsAnxietyFearHopelessnessPanicOther Please check any of the following that apply: HeadacheHigh blood pressureGastritis, esophagitis, ulcerHormone-related ProblemsHead injuryAngina or chest painIrritable bowelChronic painLoss of consciousnessHeart attackBone or joint problemsSeizuresKidney-related issuesChronic fatigueDizzinessFaintnessHeart valve problemsUrinary tract problemsFibromyalgiaNumbness & tinglingShortness of breathDiabetesHepatitisAsthmaArthritisThyroid issuesHIV/AIDSCancerOther Specify all psychotropic medications you are currently taking, for how long, and for what reason. What is the dosage of each? What time of day do you take it? Does it help? * Have you seen a mental health professional before? * YesNo If so, please specify dates, the reason for counseling, your experience, and diagnosis (if any). Who is your primary care doctor? Please include the type of doctor, name, and phone number. Do you smoke cigarettes or use any nicotine products? * YesNo, I don't use any nicotine products. If so, what and how often? Do you use them during sleeping hours? Do you currently drink alcohol? * YesNo If so, describe the type, amount, and how often. Do you currently use recreational drugs? * YesNo If so, describe type, amount, and frequency. Have you experienced any problems (legal, medical, relationship, or employment) due to alcohol or drug use? YesNo Please describe these problems. What else would you like me to know?
