Mental Health Adult Intake Form

Please complete all information, front and back of these forms and bring to the first visit. It may
seem long, but most of the questions require only a check, so it will go quickly. This form is required for
your initial intake appointment, so if it is not completed, you will be asked to fill it out in the lobby before
seeing your provider. Thank you 

Name: Click or tap here to enter text. Date: Click or tap here to enter text.
Date of Birth: Click or tap here to enter text. Primary Care Dr: Click or tap here to enter text.
Do you give permission for regular on-going updated to your Primary Care Provider? Y N

What are your main concern(s) for which you are seeking assistance?
1 Click or tap here to enter text.
.
2 Click or tap here to enter text.
.
3 Click or tap here to enter text.
.

Current Symptoms Checklist: (check once for any symptoms present):

☐ Racing thoughts ☐ Decreased need for sleep ☐ Avoidance

☐ Impulsivity ☐ Excessive energy ☐ Crying spells
☐ Increased risky behavior ☐ Excessive worry ☐ Excessive guilt
☐ Increased libido ☐ Anxiety attacks ☐ Suspiciousness
☐ Decreased libido ☐ Increased irritability ☐ Hallucinations

Suicide Risk Assessment:

Have you ever had feelings or thoughts that you didn't want to live? Yes No. If YES,
please answer the following below. If NO, please skip to the next section. (Depression Scale)

Do you currently feel that you don't want to live? ☐ Yes ☐ No

How often do you have these thoughts?
Click or tap here to enter text.
When was the last time you had thoughts of dying?
Click or tap here to enter text.
Has anything happened recently to make you feel this way?
Click or tap here to enter text.
Have you had recent thoughts of suicide? ☐ Yes ☐ No
If Yes, do you have a plan? (please explain) ☐ Yes ☐ No
Click or tap here to enter text.
Is there anything that would stop you from killing yourself? (please explain) ☐ Yes ☐ No
Click or tap here to enter text.
Do you feel hopeless and/or worthless? ☐ Yes ☐ No
Have you ever tried to kill or harm yourself before? ☐ Yes ☐ No
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DEPRESSION SCREEN:
Over the past TWO weeks, how often have you been Not at Several Half Nearly
bothered by the follow concerns? all Days the Everyday
days
1. Little interest or pleasure in doing things ☐ ☐ ☐ ☐
2. Feeling down, depressed, or hopeless ☐ ☐ ☐ ☐
3. Trouble falling or staying asleep, or sleeping
☐ ☐ ☐ ☐
too much
4. Feeling tired or having little energy ☐ ☐ ☐ ☐
5. Poor appetite or overeating ☐ ☐ ☐ ☐
6. Feeling bad about yourself---or that you are a
☐ ☐ ☐ ☐
failure or have let yourself or your family down
7. Trouble concentrating on things such as reading ☐ ☐ ☐ ☐
8. 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
9. Thoughts that you would be better off dead or
☐ ☐ ☐ ☐
of hurting yourself in some way

How difficult have these concerns impacted your work, home life or relationships? (please ✘ one)
Not difficult at all Somewhat difficult Very difficult Extremely difficult

Anxiety Screen:
Over the past TWO weeks, how often have you been Not at Several Half the Nearly
bothered by the following concerns? all Days days Everyday
1. Feeling nervous, anxious or on edge ☐ ☐ ☐ ☐
2. Not being able to stop or control worrying ☐ ☐ ☐ ☐
3. Worrying too much about different things ☐ ☐ ☐ ☐
4. Troubling relaxing ☐ ☐ ☐ ☐
5. Being so restless that it is hard to sit still ☐ ☐ ☐ ☐
6. Becoming easily annoyed or ☐ ☐ ☐ ☐
7. Feeling afraid as if something awful might happen ☐ ☐ ☐ ☐

Trauma Screening:
Have you been threatened with death, serious injury or sexual violence? ☐ Yes ☐ No
Do you have intense memories of a previous traumatic events? ☐ Yes ☐ No
Do you avoid people, places or things associated with a traumatic event? ☐ Yes ☐ No
Have your thoughts/moods been negatively impacted by a traumatic event? ☐ Yes ☐ No
Do you feel numb, detached or isolated from other? ☐ Yes ☐ No
Do you have intense mood swings (Sudden change in your mood) ☐ Yes ☐ No
Have you been abused emotionally, sexually, physically or by neglect? When, ☐ Yes ☐ No
Where and by whom?
Click or tap here to enter text.

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 List ALL your current medications, how often you take them, and how long you’ve been taking
them (if none, write none)

Medication name: Dosage? (Example: One Pill twice a day – How long on
30mg per pill) medication?
Click or tap here to enter Click or tap here to enter text. Click or tap here to enter
text. text.
Click or tap here to enter Click or tap here to enter text. Click or tap here to enter
text. text.
Click or tap here to enter Click or tap here to enter text. Click or tap here to enter
text. text.
Click or tap here to enter Click or tap here to enter text. Click or tap here to enter
text. text.

List ALL over the counter medications that you take and how often:
Name of Medication How often
Click or tap here to enter text. Click or tap here to enter text.
Click or tap here to enter text. Click or tap here to enter text.
Click or tap here to enter text. Click or tap here to enter text.

Legal Info:

Have you ever been arrested? ☐ Yes ☐ No

Do you have any pending Legal issues? ☐ Yes ☐ No
Is this Visit referred by the courts, probation office, or any other legal entities? ☐ Yes ☐ No

Past Psychiatric History:

Have you received Outpatient counseling services at any other facilities? ☐ Ye ☐ No

s
Where: Click or tap here to enter text. Reason: Click or tap here to enter text.
When: Click or tap here to enter text. Provider: Click or tap here to enter text.
Where: Click or tap here to enter text. Reason: Click or tap here to enter text.
When: Click or tap here to enter text. Provider: Click or tap here to enter text.
Have you ever been admitted for Mental Health issues before? List the latest ☐ Ye ☐ No
s
Where: Click or tap here to enter text. Reason: Click or tap here to enter text.
When: Click or tap here to enter text. Provider: Click or tap here to enter text.
Where: Click or tap here to enter text. Reason: Click or tap here to enter text.
When: Click or tap here to enter text. Provider: Click or tap here to enter text.

Past Psychiatric Medications: (please all that apply)

Antidepressants: Prozac (fluoxetine)

Zoloft (sertraline)

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 Luvox (fluvoxamine) Prolixin (fluphenazine)
Paxil (paroxetine)
Celexa (citalopram)
Lexapro (escitalopram) Sleep Medications:
Effexor (venlafaxine) Ambien (zolpidem)
Cymbalta (duloxetine) Sonata (zaleplon)
Wellbutrin (bupropion) Rozerem (ramelteon)
Remeron (mirtazapine) Restoril (temazepam)
Desyrel (trazodone)
Mood Stabilizers:
Tegretol (carbamazepine) ADHD medications
Lithium Adderall (amphetamine)
Depakote (valproate) Concerta (methylphenidate)
Lamictal (lamotrigine) Ritalin (methylphenidate)
Topamax (topiramate) Strattera (atomoxetine)

Antipsychotics/Mood Stabilizers: Antianxiety medications:

Abilify (aripiprazole) Xanax (alprazolam)
Risperdal (risperidone) Ativan (lorazepam)
Seroquel (quetiapine) Klonopin (clonazepam)
Zyprexa (olanzepine) Valium (diazepam)
Geodon (ziprasidone) Tranxene (clorazepate)
Clozaril (clozapine) Buspar (buspirone)
Haldol (haloperidol)

Family Psychiatric History:

Has anyone in your family been diagnosed with or treated for any of the following:
☐ Bipolar disorder Who: Click or tap here to enter text.
☐ Schizophrenia Click or tap here to enter text.
☐ Depression Click or tap here to enter text.
☐ Post-traumatic stress Click or tap here to enter text.
☐ Anxiety Click or tap here to enter text.
☐ Alcohol abuse Click or tap here to enter text.
☐ Anger Click or tap here to enter text.
☐ Violence Click or tap here to enter text.
☐ Other substance abuse Click or tap here to enter text.
☐ Suicide Click or tap here to enter text.

Substance Use:
Do you think you may have a problem with alcohol or drug use? ☐ Yes ☐ No
Have you ever been treated for alcohol or drug use or abuse? ☐ Yes ☐ No
Where: Click or tap here to enter text. When: Click or tap here to enter text.
What substance: Click or tap here to enter text.

Check if you have ever tried the following: If yes, how long and when did you
last use?
Marijuana ☐ Yes ☐ No Click or tap here to enter text.
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 Alcohol ☐ Yes ☐ No Click or tap here to enter text.
Methamphetamine ☐ Yes ☐ No Click or tap here to enter text.
Pain killers (not as ☐ Yes ☐ No Click or tap here to enter text.
prescribed)
Stimulants (pills) ☐ Yes ☐ No Click or tap here to enter text.
Cocaine ☐ Yes ☐ No Click or tap here to enter text.
Heroin ☐ Yes ☐ No Click or tap here to enter text.
Methadone ☐ Yes ☐ No Click or tap here to enter text.
Sleeping pills ☐ Yes ☐ No Click or tap here to enter text.
Ecstasy ☐ Yes ☐ No Click or tap here to enter text.
Other ☐ Yes ☐ No Click or tap here to enter text.

Tobacco Use:
Do you currently smoke cigarettes, cigars, pipe or use chewing tobacco? ☐ Yes ☐ No
If no, have you used in the past? ☐ Yes ☐ No
How many cigarettes or packs do/did you use a day? Click or tap here to enter text.
How many times do/did you use cigars, pipe or Click or tap here to enter text.
chewing tobacco a day?
How long have/did you use tobacco products? Click or tap here to enter text.
When did you stop using tobacco products? Click or tap here to enter text.

How many caffeinated beverages do you drink a day?

0-1 1-2 3-4 5-6 None
Coffee ☐ ☐ ☐ ☐ ☐
Soda ☐ ☐ ☐ ☐ ☐
Tea ☐ ☐ ☐ ☐ ☐
Energy Drink ☐ ☐ ☐ ☐ ☐

Family Background and Childhood:

Where did you grow up? Click or tap here to enter text.
List your siblings and their ages: Click or tap here to enter text.
Click or tap here to enter text.
Has anyone in your immediate family died?
Click or tap here to enter text.

Past Medical History:

Any Allergies? ☐ Yes ☐ No If Yes please list below:
Click or tap here to enter text.
Current Weight: Click or tap here to enter text. Height: Click or tap here to enter text.
Current Medical problem? Please list below if Yes: ☐ Yes ☐ No
Click or tap here to enter text.
Any past medical problems, surgeries, or prolonged hospital stays? ☐ Yes ☐ No
Please list, when and why: Click or tap here to enter text.
Do you exercise regularly? ☐ Yes ☐ No

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For women only:
Are you currently working?
☐ Working ☐ Studen ☐ Unemployed ☐ Disable ☐ Retired
t d
How long have you been working in your current position?
Click or tap here to enter text.
What is/ was your current position?
Click or tap here to enter text.
Have you served in the military? ☐ Yes ☐ No
Date of your last menstrual period? Click or tap here to enter text.
Are you expecting or think you might be expecting? ☐ Yes ☐ No
Are you planning on becoming pregnant soon? ☐ Yes ☐ No
What type of birth control are you currently using if any? Click or tap here to enter text.
How many pregnancies have you had? Click or tap here to enter text.

Personal and Family Medical History:

Have you or your family had any of the following? Check below
Medical Condition Yourself Family
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 ☐ ☐
Liver problems ☐ ☐

Occupational History:

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Relationship History and Current Family:
Are you currently any of the following below and for how long? Click or tap here to enter text.
☐ Married ☐ Partnered ☐ Divorced ☐ Single ☐ Widowed
Are you currently in a relationship and for how long? ☐ Yes ☐ No
Click or tap here to enter text.
Are you sexually active? ☐ Yes ☐ No
How do you identify your sexual orientation? Click or tap here to enter text.
Straight/Heterosexual Bisexual Unsure Other
Gay/Lesbian Trans Asexual Prefer not to answer

Do you have any children? List genders and ages below: ☐ Yes ☐ No
Click or tap here to enter text.
Who all currently lives with you?
Click or tap here to enter text.
Click or tap here to enter text.

Spiritual Life:
Do you belong to a particular religion or spiritual group? Yes No
Are you heavily involved in your religion or spirituality? Yes No
Do you find your involvement during hard times? More helpful More Stressful

Other comments or concerns:

Click or tap here to enter text.

Signature_________________________________________________Date____________

Emergency Contact ______________________________Telephone # ________________

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