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Adult Intake Form

Adult Intake

Form

Referred By

Today's Date

First Name

Last Name

Date Of Birth

Sex

Marital Status

Address

City

State

Zip Code

Home Phone

Cell

Work Number

Email Address

Emergency Contact

Phone

Occupation

Place of Employment

Others In Household (children, parents, etc.)
NAME: FIRST AND LAST RELATIONSHIP DOB AGE/OCCUPATION

Payment Options

Card Number

Exp Date

Sec Code

Name of Primary Care Physician

Phone

Address

Name of Therapist/Psychiatrist

Phone

Address

Family History
Has anyone in your family (blood relative) suffered emotional problems, anxiety, depression, bipolar illness, schizophrenia, panic disorder, phobias, eating disorders, or other stress related conditions? If yes, please list the family member(s) and describe the problem.

If the answer is Yes please describe

Has anyone in your family (blood relative) had problems with alcohol, drugs, or prescription medications? If yes, please list the family member(s) and describe the problem.

If the answer is Yes please describe

Has anyone in your family ever attempted or committed suicide? If yes, please list the family member(s) and describe the incident(s).

If the answer is Yes please describe

Father
Father's age

If deceased, when did he die?

Cause of death

Type of work

Times married

Describe your father’s personality and the type of relationship you had growing up

Mother
Mother's age

If deceased, when did she die?

Cause of death

Type of work

Times married

Describe your mother’s personality and the type of relationship you had growing up

Siblings
How many brothers do you have?

Sisters?

Please list their names/ages/occupations/marital status

Personal History
Date of birth

Place of birth

Please list in order all the cities and states in which you have lived and include number of years (and age) you resided in each city

Did you suffer from any traumatic experiences as a child?

If the answer is Yes please describe

Did you have any juvenile behavioral problems?

Education
Name of school &
highest grade (1-12)

Name of college &
highest grade

Name of graduate school & highest grade

Social History
Sexual preference

How many serious relationships have you had and for how long?

Were you ever abused?

If so, how?

Marital Status

Times married

Age of significant other

Education of individual

What type of work do they do?

Relationship going well?

Are there any problems?

Any children?

If yes, please list their names and ages

Any problems with your children?

If yes, please specify which children and describe below

Occupational History
Please list your jobs, starting with the first job and going through to your most recent job. Also, please list next to each job how many years you were employed in that position.

Substance Use History
Do you smoke or have you smoked cigarettes?

If yes, how much? Have you quit?

Do you drink or have you drank alcohol?

If yes, how much? Have you quit?

Do you use drugs or have you used drugs?

If yes, how much? Have you quit?

Have you ever been involved in a substance abuse, alcohol treatment or detoxification program?

If yes, please describe when and where.

Medical History
Please list any medical problems that you have and when these conditions were diagnosed.

Please list all operations that you have had including any operations that you may have had as a child

Have you ever had a head injury in which you were knocked unconscious?

If yes, please describe when and where.

Medications
Please list all your present medication.

Psychiatric History
Have you ever received any psychiatric, psychological, emotional treatment/counseling or hospitalization in the past?

If yes, please list Year(s)/Age Treatment Provider (Dr./Place) Frequency Hospitalization

Have you ever been prescribed psychiatric medications?

If yes, please list Year(s)/Age Medication How often?