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Forms/Intake-Forms/FRM-MHO-001-New-Patient-Intake.md

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+# Mental Health New Patient Intake Form
+
+| Form ID | FRM-MHO-001 | Revision | 1.0 |
+|---------|-------------|----------|-----|
+
+---
+
+## Patient Information
+
+| Field | Entry |
+|-------|-------|
+| Last Name | |
+| First Name | |
+| Preferred Name | |
+| Date of Birth | |
+| Age | |
+| Sex | ☐ Male ☐ Female ☐ Other |
+| Gender Identity | |
+| Pronouns | |
+
+### Contact Information
+
+| Field | Entry |
+|-------|-------|
+| Address | |
+| City, State, ZIP | |
+| Home Phone | |
+| Cell Phone | |
+| Email | |
+| Preferred Contact Method | ☐ Home ☐ Cell ☐ Email |
+| OK to Leave Detailed Message? | ☐ Yes ☐ No |
+
+---
+
+## Emergency Contact
+
+| Field | Entry |
+|-------|-------|
+| Name | |
+| Relationship | |
+| Phone | |
+| Address | |
+
+---
+
+## Referral Information
+
+| Field | Entry |
+|-------|-------|
+| Referred By | |
+| Referring Provider Phone | |
+| Primary Care Physician | |
+| PCP Phone/Fax | |
+| Current Therapist (if any) | |
+| Current Prescriber (if any) | |
+
+---
+
+## Reason for Seeking Treatment
+
+**What brings you in for treatment today?**
+
+**What are your main symptoms or concerns?**
+
+**When did these symptoms start?**
+
+**What do you hope to get out of treatment?**
+
+---
+
+## Symptom Checklist
+
+*Check all symptoms you are currently experiencing:*
+
+### Mood Symptoms
+☐ Depressed mood
+☐ Loss of interest/pleasure
+☐ Hopelessness
+☐ Guilt
+☐ Irritability
+☐ Mood swings
+☐ Elevated/euphoric mood
+☐ Decreased need for sleep
+☐ Racing thoughts
+☐ Increased energy
+
+### Anxiety Symptoms
+☐ Excessive worry
+☐ Restlessness
+☐ Difficulty concentrating
+☐ Muscle tension
+☐ Sleep problems
+☐ Panic attacks
+☐ Fear of social situations
+☐ Specific phobias
+☐ Obsessive thoughts
+☐ Compulsive behaviors
+
+### Trauma Symptoms
+☐ Flashbacks/intrusive memories
+☐ Nightmares
+☐ Avoiding reminders of trauma
+☐ Emotional numbness
+☐ Hypervigilance
+☐ Easily startled
+
+### Psychotic Symptoms
+☐ Hearing voices
+☐ Seeing things others don't see
+☐ Paranoid thoughts
+☐ Unusual beliefs
+☐ Confused thinking
+
+### Other Symptoms
+☐ Difficulty concentrating
+☐ Memory problems
+☐ Impulsivity
+☐ Anger problems
+☐ Relationship difficulties
+☐ Work/school problems
+☐ Appetite changes
+☐ Weight changes
+☐ Fatigue/low energy
+☐ Chronic pain
+
+---
+
+## Suicidal/Self-Harm History
+
+| Question | Response |
+|----------|----------|
+| Are you currently having thoughts of suicide? | ☐ Yes ☐ No |
+| Are you currently having thoughts of harming yourself? | ☐ Yes ☐ No |
+| Have you ever attempted suicide? | ☐ Yes ☐ No |
+| If yes, when and how? | |
+| Have you ever engaged in self-harm (cutting, burning, etc.)? | ☐ Yes ☐ No |
+| If yes, describe: | |
+
+---
+
+## Psychiatric History
+
+### Previous Treatment
+
+| Treatment Type | Yes/No | Where | When | Helpful? |
+|----------------|--------|-------|------|----------|
+| Outpatient therapy | ☐ | | | ☐ Yes ☐ No |
+| Outpatient psychiatry | ☐ | | | ☐ Yes ☐ No |
+| Intensive outpatient (IOP) | ☐ | | | ☐ Yes ☐ No |
+| Partial hospitalization (PHP) | ☐ | | | ☐ Yes ☐ No |
+| Psychiatric hospitalization | ☐ | | | ☐ Yes ☐ No |
+| Residential treatment | ☐ | | | ☐ Yes ☐ No |
+| ECT | ☐ | | | ☐ Yes ☐ No |
+| TMS | ☐ | | | ☐ Yes ☐ No |
+
+### Previous Diagnoses
+
+*Check all that you have been diagnosed with:*
+
+☐ Depression
+☐ Bipolar Disorder
+☐ Anxiety Disorder
+☐ Panic Disorder
+☐ PTSD
+☐ OCD
+☐ ADHD
+☐ Schizophrenia/Schizoaffective
+☐ Personality Disorder (type: _______)
+☐ Eating Disorder
+☐ Substance Use Disorder
+☐ Autism Spectrum Disorder
+☐ Other: _______________
+
+---
+
+## Current Medications
+
+| Medication | Dose | Frequency | Prescriber |
+|------------|------|-----------|------------|
+| | | | |
+| | | | |
+| | | | |
+| | | | |
+| | | | |
+
+### Past Psychiatric Medications
+
+*List medications you have tried in the past:*
+
+| Medication | Helpful? | Side Effects? | Reason Stopped |
+|------------|----------|---------------|----------------|
+| | ☐ Yes ☐ No | | |
+| | ☐ Yes ☐ No | | |
+| | ☐ Yes ☐ No | | |
+| | ☐ Yes ☐ No | | |
+
+---
+
+## Allergies
+
+☐ No Known Allergies
+
+| Medication/Substance | Reaction |
+|---------------------|----------|
+| | |
+| | |
+
+---
+
+## Substance Use History
+
+| Substance | Ever Used | Age First Used | Current Use | Amount/Frequency | Last Used |
+|-----------|-----------|----------------|-------------|------------------|-----------|
+| Alcohol | ☐ | | ☐ | | |
+| Marijuana/Cannabis | ☐ | | ☐ | | |
+| Cocaine/Crack | ☐ | | ☐ | | |
+| Heroin/Opioids | ☐ | | ☐ | | |
+| Methamphetamine | ☐ | | ☐ | | |
+| Benzodiazepines (non-Rx) | ☐ | | ☐ | | |
+| Tobacco/Nicotine | ☐ | | ☐ | | |
+| Other: | ☐ | | ☐ | | |
+
+**Have you ever had treatment for substance use?** ☐ Yes ☐ No
+
+If yes, describe:
+
+---
+
+## Medical History
+
+### Current Medical Conditions
+
+☐ None
+
+| Condition | Notes |
+|-----------|-------|
+| | |
+| | |
+| | |
+
+### Past Surgeries/Hospitalizations
+
+| Surgery/Hospitalization | Year |
+|------------------------|------|
+| | |
+| | |
+
+### For Women
+
+| Field | Entry |
+|-------|-------|
+| Are you pregnant? | ☐ Yes ☐ No ☐ Maybe |
+| Are you breastfeeding? | ☐ Yes ☐ No |
+| Last menstrual period | |
+| Using contraception? | ☐ Yes ☐ No |
+
+---
+
+## Family Psychiatric History
+
+*Check all that apply to biological relatives:*
+
+| Condition | Mother | Father | Sibling | Grandparent | Other |
+|-----------|--------|--------|---------|-------------|-------|
+| Depression | ☐ | ☐ | ☐ | ☐ | ☐ |
+| Bipolar Disorder | ☐ | ☐ | ☐ | ☐ | ☐ |
+| Anxiety | ☐ | ☐ | ☐ | ☐ | ☐ |
+| Schizophrenia | ☐ | ☐ | ☐ | ☐ | ☐ |
+| Substance Abuse | ☐ | ☐ | ☐ | ☐ | ☐ |
+| Suicide/Attempt | ☐ | ☐ | ☐ | ☐ | ☐ |
+| ADHD | ☐ | ☐ | ☐ | ☐ | ☐ |
+| Other: | ☐ | ☐ | ☐ | ☐ | ☐ |
+
+---
+
+## Social History
+
+### Living Situation
+
+| Field | Entry |
+|-------|-------|
+| Who do you live with? | |
+| Type of housing | ☐ Own ☐ Rent ☐ With family ☐ Homeless ☐ Other |
+| Housing stability | ☐ Stable ☐ At risk ☐ Unstable |
+
+### Relationships
+
+| Field | Entry |
+|-------|-------|
+| Marital/Relationship status | ☐ Single ☐ Married ☐ Partnered ☐ Divorced ☐ Widowed |
+| Children (ages) | |
+| Quality of relationships | ☐ Good ☐ Fair ☐ Poor |
+| Social support | ☐ Strong ☐ Some ☐ Limited ☐ None |
+
+### Education/Employment
+
+| Field | Entry |
+|-------|-------|
+| Highest education | |
+| Current employment | ☐ Full-time ☐ Part-time ☐ Unemployed ☐ Disabled ☐ Retired ☐ Student |
+| Occupation | |
+| Work/school problems? | ☐ Yes ☐ No |
+
+### Legal
+
+| Field | Entry |
+|-------|-------|
+| Current legal issues? | ☐ Yes ☐ No |
+| If yes, describe: | |
+| History of incarceration? | ☐ Yes ☐ No |
+
+### Trauma History
+
+*Have you experienced any of the following?*
+
+☐ Physical abuse
+☐ Sexual abuse
+☐ Emotional/verbal abuse
+☐ Neglect
+☐ Domestic violence
+☐ Witnessed violence
+☐ Military combat
+☐ Serious accident
+☐ Natural disaster
+☐ Other trauma: _______________
+
+---
+
+## Current Stressors
+
+*Rate your current stress level (1-10):* _____
+
+*What are your main stressors right now?*
+
+---
+
+## Strengths and Supports
+
+*What are your strengths?*
+
+*Who are your supports (family, friends, community)?*
+
+*What coping strategies do you currently use?*
+
+---
+
+## Goals for Treatment
+
+*What would you like to accomplish through treatment?*
+
+1.
+2.
+3.
+
+---
+
+## Signature
+
+| Field | Entry |
+|-------|-------|
+| Patient Signature | |
+| Date | |
+| Guardian Signature (if minor) | |
+| Relationship to Patient | |
+
+---
+
+## For Office Use
+
+| Field | Entry |
+|-------|-------|
+| Date Received | |
+| Entered By | |
+| Appointment Date | |
+| Assigned Provider | |
+| Notes | |
+
+---
+
+*Form FRM-MHO-001 Rev 1.0 - Mental Health New Patient Intake Form*