ADULT INTAKE INFORMATION FORM

    Please complete this form as best as you can and submit prior to your intake appointment. Please know this form is reviewed during the intake and if not complete prior to your scheduled intake appointment, the appointment will be delayed and may have to be rescheduled.

    Part 1 - IDENTIFYING DATA
    Name (Last, First, MI)

    Birth Date:
    Today's Date:
    Address:
    Home Phone:
    Work Phone:
    Cell Phone:
    Email Address:
    Gender:
    MaleFemaleOther

    If "Other," Please Specify:
    Part 2 - PRESENTING PROBLEM
    What is (are) your reason(s) for coming in today?
    How long have you been experiencing these problems?
    Have you had difficulties like this before?
    YesNo
    If "Yes," please explain:
    Are you having any self-destructive or suicidal thoughts?
    YesNo
    If "Yes," please explain:
    Part 3 - PAST PSYCHIATRIC HISTORY

    List any previous psychiatric or substance abuse evaluations, counseling or hospitalizations.

    Reason

    Location

    Dates

    Diagnosis (if known)

    List any previous psychiatric medication therapy.

    Medication

    Dates

    Effectiveness

    Side Effects

    Discontinued Reason

    Have you ever attempted suicide in the past?
    YesNo
    If "Yes," please explain:
    Part 4 - MEDICAL HISTORY
    Name and Location of Health Care Provider:
    Office Phone of Health Care Provider Office:
    List all allergies and reactions to medications:

    List all medications that you are currently taking (please continue in Part 18 if more space required):

    Name of Drug

    Amount Taken (dose)

    Name of Drug

    Amount Taken (dose)

    List all current and past medical or physical problems, including hospitalizations and traumatic injuries:
    Are you currently experiencing severe pain, fever, dizziness, or lightheadedness?
    YesNo
    List any over the counter medications:
    Herbal Products:
    Supplements/Vitamins
    Part 4A - PAIN ASSESSMENT
    Are you currently experiencing any physical pain?
    YesNo
    If "Yes," please explain:

    (If experiencing pain, please score your pain on a 10 point scale where 0 = no pain and 10 = worst pain imaginable)

    Please score your pain:
    012345678910
    Good pain day:
    /10
    Average pain day:
    /10
    Bad pain day:
    /10
    What do you do to help you manage your pain on severe pain days?
    Part 5 - SUBSTANCE USE ASSESSMENT
    In the past year, have you ever drunk alcohol or used drugs more than you intended?
    YesNo
    In the past year, have you felt you wanted or needed to cut down on your alcohol or drug use?
    YesNo
    What, if any, recreational or illicit drugs or medications have you used recently or in the past?
    Did you ever find that you needed to drink a lot more or use more drugs in order to get an effect, or that you could no longer get high on the amount that you were using?
    YesNoN/A
    AUDIT Screening Tool

     

    0

    1

    2

    3

    4

    Please check the box that most applies to you.

    Never

    Monthly or Less

    2-4 Times Monthly

    2-3 Times Weekly

    4+ Time Weekly

    1. How often do you have a drink containing alcohol?

    Never

    X

    Monthly or Less

    X

    2-4 Times Monthly

    X

    2-3 Times Weekly

    X

    4+ Times Weekly

    X

     

    1-2

    3-4

    5-6

    7-9

    10+

    2. How many drinks containing alcohol do you have on a typical day when you are drinking?

    1-2

    X

    3-4

    X

    5-6

    X

    7-9

    X

    10+

    X

     

    Never

    Monthly or Less

    Monthly

    Weekly

    Daily or Close

    3. How often do you have six or more drinks on one occasion?

    Never

    X

    Monthly or Less

    X

    Monthly

    X

    Weekly

    X

    Daily or Close

    X

     

    4. How often during the last year have you found that you were not able to stop drinking once you had started?

    Never

    X

    Monthly or Less

    X

    Monthly

    X

    Weekly

    X

    Daily or Close

    X

     

    5. How often during the last year have you failed to do what was normally expected of you because of drinking?

    Never

    X

    Monthly or Less

    X

    Monthly

    X

    Weekly

    X

    Daily or Close

    X

     

    6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?

    Never

    X

    Monthly or Less

    X

    Monthly

    X

    Weekly

    X

    Daily or Close

    X

     

    7. How often during the last year have you had a feeling of guilt or remorse after drinking?

    Never

    X

    Monthly or Less

    X

    Monthly

    X

    Weekly

    X

    Daily or Close

    X

     

    8. How often during the last year have you been unable to remember what happened the night before because of drinking?

    Never

    X

    Monthly or Less

    X

    Monthly

    X

    Weekly

    X

    Daily or Close

    X

     

    Never

     

    Yes, but not in the last year

     

    Yes, during the last year

    9. Have you or someone else been injured as a result of your drinking?

    Never

    X

     

    Yes, but not in last year

    X

     

    Yes, during the last year

    X

     

    10. Has anyone been concerned about your drinking or suggested that you should cut down

    Never

    X

     

    Yes, but not in last year

    X

     

    Yes, during the last year

    X

    Total AUDIT Score
    Column 0
    Column 1
    Column 2
    Column 3
    Column 4
    Tobacco Use
    Do you smoke or use tobacco products? (If no, please go to the next section)
    YesNo

    What do you smoke or use?

    CigarettesSnuffCigarsPipe

    If other than those listed, please specify:
    How much do you use in a day?
    How long have you been using tobacco products?
    Do you wish to quit?
    YesNo
    Caffeine Use
    How many caffeinated beverages do you consume per day on average?
    Do you ever feel irritable, jumpy or nervous because of your caffeine use?
    YesNo
    Does caffeine use impair your sleep?
    YesNo
    Part 6 - FAMILY PSYCHIATRIC HISTORY

    Relationship

    Problem/Diagnosis

    Hospitalized

    Medications Prescribed?

    Hospitalized?

    YesNo

    Hospitalized?

    YesNo

    Hospitalized?

    YesNo

    Hospitalized?

    YesNo

    Have there been any deaths or suicidal behavior in your family?
    YesNo
    If "Yes," please explain:
    Part 7 - PSYCHOSOCIAL/DEVELOPMENTAL HISTORY
    Where were you born?

    Who raised you?

    Both ParentsMotherFatherOther FamilyFoster Parent(s)Adoptive Parent(s)Other

    If "Other," please explain:
    Were there any complications at birth?
    YesNo
    If "Yes," please explain:
    How many siblings do you have and what number child were you?

    What was it like in your childhood home?

    LovingComfortableSupportiveChaoticAbusiveOther

    If "Other," please explain:
    What type of discipline was used in your childhood home?

    Did you have any developmental delays or problems?

    YesNo

    If "Yes," please explain:

    Have you ever been physically, sexually or emotionally abused?

    YesNo

    If "Yes," please explain:
    Part 8 - CURRENT FAMILY RELATIONSHIP ASSESSMENT
    Marital Status
    SingleMarriedDivorcedSeparatedWidowed
    If married, for how long?

    If married, are you currently having any stressors or problems in your marriage?

    YesNoN/A

    If "Yes," please explain:

    Have you been married previously?

    YesNoN/A

    If "Yes," please explain:

    Do you have any concerns about domestic violence or abuse?

    YesNo

    If "Yes," please explain:

    Have you or any of your spouses ever been referred to any agency such as Child Protective Services?

    YesNo

    If "Yes," please explain:

    Please list all your children: (continue below, if needed)

    N/A

    Child's Name

    Child's Age

    Child's Gender

    Biological or Stepchild?

    Does this child currently reside with you?

    BiologicalStepchild
    BiologicalStepchild
    BiologicalStepchild
    BiologicalStepchild
    BiologicalStepchild

    Does anyone else reside in your household?

    YesNo

    Are you having any problems with your children?

    YesNo

    If "Yes" to either question, please explain:
    Part 9 - RISK ASSESSMENT

    Are there any firearms in your home?

    YesNo

    Is there any history of domestic violence in your home?

    YesNo

    Do you have a history of suicidal or self-destructive thoughts or behaviors?

    YesNo

    Do you have a history of homicidal (harm to others) thoughts or behaviors?

    YesNo

    Do you have any other safety concerns at this time?

    YesNo

    If "Yes," please explain:
    Part 10 - SOCIAL SUPPORT ASSESSMENT

    Do you have someone to talk to when you have a problem?

    YesNo

    Is there someone you would ask for help if you needed it?

    YesNo

    Are you geographically separated from family and friends?

    YesNo

    Are you having trouble with your relationships with family, friends or coworkers?

    YesNo

    Have you recently withdrawn from family or friends?

    YesNo

    Do you belong to any groups or organizations that are supportive and helpful to you?

    YesNo

    If "Yes," please explain:
    Part 11 - SPIRITUAL/CULTURAL ASSESSMENT
    What is your religious or spiritual affiliation?

    How much is your religion or spirituality a source of strength or comfort to you?

    Not at allNot very muchSomewhatQuite a bitA great deal

    How much is your spiritual community a source of support to you?

    Not at allNot very muchSomewhatQuite a bitA great deal

    Do you have any religious, spiritual or cultural practices that your provider needs to be aware of during treatment?

    YesNo

    If "Yes," please explain:

    Part 12 - EDUCATIONAL ASSESSMENT
    Highest Level of Education Completed
    GED
    Some College
    High School
    Year Graduated
    4yr College
    Year Graduated
    Masters
    Year Graduated
    Doctoral
    Year Graduated
    Are you currently in school or training?
    YesNo
    Did you repeat or skip any grades?
    YesNo
    Did you attend any special education or gifted classes?
    YesNo
    Did you have any learning disabilities?
    YesNo
    Did you have any disciplinary problems in school?
    YesNo
    Were you ever suspended or expelled?
    YesNo
    If you answered "Yes" to any of the above, please explain:
    Part 13 - LEGAL ASSESSMENT
    Have you ever been arrested?
    YesNo
    Are you currently on probation or parole?
    YesNo
    Do you presently have any other legal problems?
    YesNo
    If you answered "Yes" to any of the above, please explain:
    Part 14 - SEXUAL ASSESSMENT
    Are you experiencing any sexual concerns?
    YesNo
    Have you ever been sexually abused, assaulted or harassed?
    YesNo
    If you answered "Yes" to any of the above, please explain:
    Part 15 - LEISURE, RECREATIONAL AND VOCATIONAL ACTIVITIES
    What is your present job?
    Are there any problems with your present job?
    What do you like to do in your free time?
    What limits your ability or desire to participate in leisure and recreational activities?
    Part 16 - NUTRITIONAL ASSESSMENT
    Height:
    Weight:
    In the last month have you gained or lost weight without trying? (If yes, please explain below)
    YesNo
    How many meals do you eat per day?
    Have you ever had problems with: (If yes, please explain below)
    Being OverweightBeing UnderweightBinge EatingCompulsive OvereatingVomitingLaxative AbuseExcessive DietingDiureticOther Eating Disorders/Problems
    If you answered "Yes" or checked any of the above, please explain:
    Part 17 - FINANCIAL ASSESSMENT

    Do you currently have any financial problems?

    YesNo

    If "Yes," please explain:
    Part 18 - PATIENT DISCLOSURE
    Please list any individuals that you consent to have contacted regarding your care:
    Spouse (Name):
    Gather Further InformationRelease InformationMake Recommendations
    Supervisor (Name):
    Gather Further InformationRelease InformationMake Recommendations
    Doctor (Name):
    Gather Further InformationRelease InformationMake Recommendations
    Other Person/Agency (Name):
    Gather Further InformationRelease InformationMake Recommendations
    Please use this space to tell us anything additional that you may feel is relevant or may be important for your provider to know.
    Patient Signature:
    Date: