Adult intake form.

Fields marked * are required.

Referred ByToday’s Date First Name Last Name Date Of Birth Sex Marital Status AddressCity State Zip Code Home PhoneCell Work NumberEmail AddressEmergency ContactPhoneOccupationPlace of EmploymentOthers In Household(children, parents, etc.) Name: first and last, relationship, DOB, age/occupationPayment OptionsCard NumberExp DateSec CodeName of Primary Care PhysicianPhoneAddressName of Therapist/PsychiatristPhoneAddress

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 describeHas 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 describeHas 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 ageIf deceased, when did he die?Cause of deathType of workTimes marriedDescribe your father’s personality and the type of relationship you had growing up

Mother

Mother’s ageIf deceased, when did she die?Cause of deathType of workTimes marriedDescribe 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 birthPlace of birthPlease list in order all the cities and states in which you have lived and include number of years (and age) you resided in each cityDid you suffer from any traumatic experiences as a child?If the answer is Yes please describeDid you have any juvenile behavioral problems?

Education

Name of school & highest grade (1-12)Name of college & highest gradeName of graduate school & highest grade

Social History

Sexual preferenceHow many serious relationships have you had and for how long?Were you ever abused?If so, how?Marital StatusTimes marriedAge of significant otherEducation of individualWhat type of work do they do?Relationship going well?Are there any problems?Any children?If yes, please list their names and agesAny 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 childHave 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.Medication, amount, how often, how long taking it, prescribing doctor

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, HospitalizationHave you ever been prescribed psychiatric medications?If yes, please list Year(s)/Age, Medication, How often?