Specialty Behavioral Health Intake Form

SPECIALTY BEHAVIORAL HEALTH - INTAKE FORM

This information you provide will be used to plan your treatment and is held strictly confidential. You may leave any item blank if you don't feel comfortable providing an answer. After completing this form, please give it directly to your doctor or therapist at your first visit. Thank you in advance for your efforts.

Name: Social Security #:

Birth Date: Age: Gender:

Marital Status: Never Married Partnered Married Separated Divorced Widowed

Address:

May we send mail there? Yes No

Home Phone: May we leave a message? Yes No

Work Phone: May we leave a message? Yes No

Mobile Phone: May we leave a message? Yes No

E-mail: May we email you? Yes No

Please be aware that email may not be confidential.

Emergency Contact Information:

REFERRED BY:

OCCUPATION:

CULTURAL BACKGROUND:

Place of Birth: Race/Ethnicity:

Religion: How often do you attend services?

Do you or your family speak a language other than English?

Sexual Orientation: Heterosexual Homosexual Bisexual Unsure Other

FAMILY BACKGROUND:

Please list the members of your current family, including ages, occupations, and any comments about them or comments about your relationship with them:

Please list members of extended family that are key figures in your life (examples: siblings, parents, grandparents, etc):

Please check and explain any past, present, or impending family issues:

Deaths Divorce

Financial Crisis Injuries/Illness

Abuse Other

Has anyone in your family ever had:

Psychiatric problems (depression, anxiety, psychosis, etc)? Yes No Unsure

Unhealthy alcohol or drug use? Yes No Unsure

An attempted or completed suicide? Yes No Unsure

LEGAL BACKGROUND:

Do you have any current, pending, or future legal issues? Yes No Unsure

If 'Yes' or 'Unsure,' please explain:

MEDICAL AND HEALTH BACKGROUND:

Do you have any current medical problems? Yes No If 'Yes,' please describe below:

Are you currently taking any medications? Yes No If 'Yes,' please list below:

Have you been hospitalized or treated for serious medical problems in the past? Yes No

Who is your regular health care provider?

(Note: We will not contact this person without your authorization, except in case of emergency)

Are you having any trouble with your sleep? Yes No If 'Yes,' explain below.

Difficulty falling asleep Sleeping too much Waking up during night

Disturbing dreams Sleeping too little Not feeling refreshed

Are you having any difficulties with your appetite or eating habits? Yes No If 'Yes,' explain below.

Eating less Eating more Restricting Binging or out-of-control eating Diminished appetite

Do you currently drink alcohol? Yes No Have you drank alcohol in the past? Yes No

Do you currently use any drugs? Yes No Have you tried or used drugs in the past? Yes No

How many times per week do you exercise? How long each time?

What type(s) of exercise?

How do you relax yourself?

RELATIONSHIPS:

Are you currently involved in an intimate relationship? Yes No Unsure

If 'Yes' or 'Unsure:' Name: How Long:

Who do you hang-out with most often?

Who do you talk with about serious things in your life?

Who is aware of the problem(s) you are having?

Who is critical of you?

STRENGTHS AND LIKES:

Which areas of your life are going well?

Favorite hobbies or activities:

Favorite movies, books, or TV shows:

PSYCHOLOGICAL BACKGROUND:

Are you currently seeing another psychologist, psychiatrist, or therapist? Yes No

Have you ever seen a psychologist, psychiatrist, or therapist in the past for any reason? Yes No

Are you currently having thoughts about ending your life or wanting to die? Yes No

Have you had thoughts about ending your life or wanting to die in the past 3 months? Yes No

Have you ever attempted to kill or harm yourself in the past? Yes No

Are you currently having thoughts about wanting to hurt or harm somebody else? Yes No

Have you ever been involved in a physical fight or hurt somebody in the past? Yes No

Have you ever been a victim of rape or received unwanted sexual contact? Yes No Unsure

Have you ever been exposed to physical abuse, emotional abuse, or other trauma? Yes No Unsure

Have you ever witnessed a horrific or terrifying experience (e.g. death)? Yes No Unsure

PROBLEM DESCRIPTION:

Briefly describe the problem(s) for which you are seeking help:

How long have you been dealing with the problem(s)?

How has your relationships, work, or sense of well-being been affected by the problem(s)?

How have you tried to fix or cope with the problem(s)?

What are your treatment goals for the problem(s)?