BEHAVIORAL HEALTH INTAKE FORM
Name
First Name
Last Name
Todays Date
/
Month
/
Day
Year
Have you been referred to this office by anyone?
Another Provider
Myself
Other
Who is your Primary Care Provider
Reasons for seeking mental health services?
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Symptoms / Problems
Are you having any of the following problems? (Check all that apply)
Depression
Excessive worry
Hearing voices
Loss of interest
Tense Muscles
Seeing things
Hopeless
Restlessness
Forgetting how to do tasks
Worthless
Panic Attacks
Memory Problems
Poor Energy
Nightmares
Getting lost easily
Poor Self Esteem
Social Discomfort
Feeling others want to harm you
Change in appetite
Repetitive thoughts
Eating Concerns
Fatigue
Compulsive behaviors
Difficulty caring for self
Poor Focus
Obsessions
Pregnancy/abortion concerns
Sleeping Problems
Abuse
Talking too fast
Thoughts of not living
Impulsive
Tics or jerks
Mood highs/euphoria
Trouble concentrating
Substance Use
Excessive Energy
Hyperactivity
Family/Marital Conflict
Little/no need for sleep
Legal Problems
Major Medical Issues
Racing Thoughts
Sexual Abuse Offender
Stealing
Dishonesty/lying
Grief/Loss
Suicidal thoughts/behaviors
Phobias/fears
Adoption-related concerns
Anger/control issues
Gambling issues
Other
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Psychiatric Medication History:
(Any current or past psychiatric medications)
Example:
Zoloft, age 16-19, 50mg, depression, didn't work
1st Medication
2nd Medication
3rd Medication
4th Medication
5th Medication
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Behavioral Health History
Have you ever seen a psychiatrist before?
No
Yes - List provider or notes below
Have you ever seen a therapist before?
No
Yes - List provider or notes below
Have you ever been hospitalized for mental health?
No
Yes - List provider or notes below
Have you seen an addiction counselor before?
No
Yes - List provider or notes below
Diagnosed with any mental health disorders?
No
Yes - List provider or notes below
Received treatment for those diagnoses?
No
Yes - List provider or notes below
Ever tried or thought about harming yourself?
No
Yes - List provider or notes below
Ever harmed yourself? (scratching, hitting, cutting, burning)
No
Yes - List provider or notes below
Family history of suicide?
No
Yes - List provider or notes below
Past mental health diagnoses?
No
Yes - List provider or notes below
Family history of suicide?
No
Yes - List provider or notes below
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Social History, Sexual History, and Employment
Where were you born?
Who raised you and where?
Ever been arrested? Legal history?
Marital Status (married/divorced)?
Current partner's name?
Children (name/age/living with you)?
Religious or spiritual beliefs?
Are you sexually active?
Yes
No
Employment: Occupation
Employment: How long at this job?
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School and Development
(For minors under 18)
IEP or 504 Plan?
No
Yes - Provide notes below
School behavior concerns?
No
Yes - Provide notes below
Developmental delays (speech, motor, learning)?
No
Yes - Provide notes below
Any concerns about harm to self or others?
No
Yes - Provide notes below
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General Health History
Check all that may apply.
Cerebral palsy
Loss of consciousness
Vision problems
Rheumatic fever
Anemia/sickle cell disease
Prone to infections
Pneumonia
Difficulty breathing
Jaundice
Bed wetting
Thyroid/glandular disorder
Cold sores/canker sores
Arthritis/joint problems
Seizures
Head injury
Heart disease
Heart surgery
Excessive bleeding/bruising
Immune system disorder
Cystic fibrosis
Stomach or intestinal problems
Urinary tract infection
Possibly pregnant
Weight loss/gain
Muscle weakness
Fainting
Hearing Problems
Heart murmur
Blood transfusion
AIDS/HIV
Asthma
Hepatitis
Bladder or kidney problems
Diabetes
Skin problems
Limited use of arms/legs
Other
Have you been hospitalized for non-psychiatric reasons?
Yes
No
Do you have allergies to medications, food or environment?
Yes
No
If yes, allergies to what?
Any other current medications? (Ex. hypertension, diabetes, thyroid disorder, etc.)
No
Yes - Provide names, dosage, and reason for taking below.
Are you taking any over-the-counter medications or herbs?
No
Yes - Provide names, dosage, and reason for taking below.
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Family History
Please check all that apply and list relation
Alcohol/Substances
Yes
No
Relative(s)
Anxiety/Phobias
Yes
No
Relative(s)
Autism/Asperger's
Yes
No
Relative(s)
Behavioral Issues
Yes
No
Relative(s)
Family conflict
Yes
No
Relative(s)
Depression
Yes
No
Relative(s)
Learning issues
Yes
No
Relative(s)
Bipolar
Yes
No
Relative(s)
ADHD
Yes
No
Relative(s)
Psychosis
Yes
No
Relative(s)
Seizures/TBI
Yes
No
Relative(s)
Suicide History
Yes
No
Relative(s)
Tics/Tourette's
Yes
No
Relative(s)
Other Mental
No
Yes - List below.
Relative(s)
Diabetes
Yes
No
Relative(s)
High BP
Yes
No
Relative(s)
Heart Disease
Yes
No
Relative(s)
Tuberculosis
Yes
No
Relative(s)
Respiratory issues
Yes
No
Relative(s)
Hepatitis
Yes
No
Relative(s)
Seizure disorder
Yes
No
Relative(s)
Cancer
Yes
No
Relative(s)
Kidney disease
Yes
No
Relative(s)
Thyroid disease
Yes
No
Relative(s)
Blood Disorder
Yes
No
Relative(s)
Arthritis
Yes
No
Relative(s)
Legal problems
Yes
No
Relative(s)
Dementia
Yes
No
Relative(s)
Stroke/Other
Yes
No
Relative(s)
Other Medical
No
Yes - List below.
Relative(s)
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