New Client Intake Form Please fill out the following intake form prior to your appointment.Thank you. Today's Date MM DD YYYY Name * First Name Last Name Birthdate MM DD YYYY Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Insurance Name Insurance Member ID Emergency Contact Phone Number (###) ### #### Who can we thank for referring you? Legal Information Pending Charges Date of Hearing Probation/Parole Past Charges Presenting Problem and Current Symptoms Present Symptoms Attempts of Suicide (how): Age of First Attempt Self-Harming Behaviors Family History of Suicide (who/when) Past Mental Health Hospitalizations Past Mental Health Diagnoses Current Medications for Psychiatric Conditions Please list any medications you are currently taking for a psychiatric condition. Please list the dose and why the medication is prescribed Medications Who prescribed these medications? (check all that apply) My psychiatrist My physician (not a psychiatrist) Emergency Room doctor Name of Doctor Phone Number (###) ### #### Date of Last Visit Have you ever received any form of counseling or psychotherapy? Yes No Are you currently receiving any form of counseling or psychotherapy? Yes No Please list your two most recent therapies and therapists Name of Therapist Phone Number (###) ### #### Date of First Session Date of Last Session How often did you see your therapist? What Type of Therapy Approach? General supportive counseling (having someone to talk to who understands) Insight therapy (getting a better understanding of your problems) Cognitive Therapy (learning how to think differently) Cognitive-Behavioral Therapy (solving problems and learning coping skills) Group Therapy Other Name of Therapist 2 Phone Number (###) ### #### Date of First Session Date of Last Session How often did you see your therapist? What Type of Therapy Approach? General supportive counseling (having someone to talk to who understands) Insight therapy (getting a better understanding of your problems) Cognitive Therapy (learning how to think differently) Cognitive-Behavioral Therapy (solving problems and learning coping skills) Group Therapy Other Social History Place of Birth Parents (their past/current relationships) Psychiatric History of Family Siblings Marriages/Partners (past/current relationship) Children PlacesLived Past Abuse (sexual, physical, emotions, age, by who, and duration) Education Employment History/Current Substance Abuse History Current Usage/Drug of Choice Last Usage Longest Period of Abstinence Age of First Usage/What Past/Current Treatment for Substance Use Family History of Substance Use Medical Health History Name of Current Primary Care Doctor Phone Number Do you see any other medical doctors not listed above? Yes No Has a medical doctor ever tested you to examine if your psychological problems could be due to an underlying medical condition? Yes No If so, what were the results? Please describe your present major physical or health complaints, symptoms, and problems: Have you been troubled by headaches, stomachaches, other physical pains or discomfort? Are you being or have you been treated by a physician for any of these problems? The following medical conditions are associated with depression. Please indicate if you have had any of the following conditions. Degenerative Neurological Illnesses Parkinson's Disease Huntington's Disease Other Neurological Illness Cerebrovascular Disease Metabolic or Endocrine Condition B-12 Deficiency Hypothyroidism Other Endocrine Condition Autoimmune Condition Systemic Lupus Erythematosus Hepatitis Mononucleosis HIV Cancer Carcinoma of the Pancreas Other type of Cancer Current Medications for the Physical Conditions Current Medications for the Physical Conditions Please list any medications you are currently taking for a psychiatric condition. Please list the dose and for what condition the medication is prescribed. Have you ever had a head injury? Yes No If so, when were the injury(s) and did you lose consciousness? Thank you!
