7.7 KiB
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 | |
| 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?
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