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Mental Health Intake Form(all information on this form is strictly confidential)Patient First Name:Patient Last Name:Name of Person completing form (if other than patient):Date Completed:Patient Date of Birth:Primary Care Physician:Physician Phone:Current Symptoms Checklist (please check all appropriate columns)AggressionAgitationAngerAnxietyAppetite changeChange in libidoCompulsionsCrying/tearfulCyber ty getting out of bedDifficulty making decisionsDistractibilityEating disorderElevated moodEmotional trauma perpetratorEmotional trauma victimExcessive ng voicesHeart ritabilityMild Moderate Severe Judgment errorsLonelinessLoss of interest in activitiesMemory impairmentMood swingsObsessionsOppositional behaviorPanic attacksParanoiaPhobias/fearsPhysical trauma perpetratorPhysical trauma victimPoor concentrationPoor groomingRacing thoughtsRecurring thoughtsSelf-mutilationSexual addictionSexual difficultiesSexual trauma perpetratorSexual trauma victimSleep problemsSpeech problemsSocial isolationSubstance abuseSuicidal thoughtsWorriedWorthlessnessOther:Other:Other:Mild Moderate MEDICAL HISTORYCurrent MedicationsMedication NameTotal Daily DosageDescribe current physical health: Good FairList any known allergies:Past nonpsychiatric hospitalizations or surgeries:Do you exercise regularly? Yes No PoorEstimated Start DateSevere

Personal and Family Medical History (Have you or a family member ever had any of the following? If family, specify which family Behavioral problemsBirth defectsCancerChronic FatigueChronic PainDiabetesEar/Nose/Throat ProblemsEating DisorderEmotional ProblemsEndocrine/Hormone ProblemsEpilepsy or SeizuresEye ProblemsFibromyalgiaGastrointestinal ProblemsGenital/Gynecological ProblemsYou Family Who?Head InjuryHeart DiseaseHigh Blood PressureHigh CholesterolHIV Positive or AIDSKidney ProblemsLiver Problems/HepatitisLung DiseaseMental RetardationMigraine or Cluster HeadachesNeurological ProblemsSkin DiseaseSleep ApneaStrokeThyroid DiseaseTuberculosisUrological ProblemsViral Illness/HerpesOther:You Family Who?EMOTIONAL/PSYCHIATRIC HISTORYPrior Outpatient Treatment? Yes NoReasonIf yes, please describe:Dates TreatedBy WhomPrior Inpatient Treatment (for psychiatric, emotional, or substance abuse disorder)?Reason Yes NoIf yes, please describe:Date HospitalizedWhereFamily History (has anyone in your family ever been treated for any of the following)?FatherMotherAuntDepression Maternal PaternalAnxiety Panic Attacks Post Traumatic StressUncleBrotherSisterChildrenGrandparent Maternal Paternal Maternal Paternal Maternal Paternal Maternal Paternal Maternal Paternal Maternal Paternal Maternal Paternal Maternal Paternal Maternal Paternal Maternal Paternal Maternal PaternalBipolar Disorder/ManicDepression Maternal Paternal Maternal Paternal Maternal PaternalSchizophrenia Maternal Paternal Maternal Paternal Maternal PaternalAlcohol Problems Maternal Paternal Maternal Paternal Maternal PaternalDrug Problems Maternal Paternal Maternal Paternal Maternal PaternalADHD Maternal Paternal Maternal Paternal Maternal Paternal

Suicide Attempts Maternal Paternal Maternal Paternal Maternal PaternalPsychiatric Hospitalization Maternal Paternal Maternal Paternal Maternal PaternalPast Psychiatric Medications (if you have ever taken any of the following medications, indicate the date, dosage, and how helpful they were)AntidepressantsCheck if takenWhen?Dosage?Did it help?Any side effects?Prozac (fluoxetine) Yes No Yes NoZoloft (sertraline) Yes No Yes NoLuvox (fluvoxamine) Yes No Yes NoPaxil (paroxetine) Yes No Yes NoCelexa (citalopram) Yes No Yes NoEffexor (venlafaxine) Yes No Yes NoCymbalta (duloxetine) Yes No Yes NoWellbutrin (bupropion) Yes No Yes NoRemeron (mirtazapine) Yes No Yes NoSerzone (nefazodone) Yes No Yes NoAnafranil (clomipramine) Yes No Yes NoPamelor (nortrptyline) Yes No Yes NoTofranil (imipramine) Yes No Yes NoElavil (amitriptyline) Yes No Yes NoPristiq (desvenlafaxin) Yes No Yes NoDesyrel (trazadone) Yes No Yes NoViibryd (vilazodone) Yes No Yes NoAdapin (doxepin) Yes No Yes NoAsendin (amoxapine) Yes No Yes NoLudiomil (maprotiline) Yes No Yes NoNorpramin (desipramine) Yes No Yes NoSurmontil (trimipramine) Yes No Yes NoVivactil (protriptyline) Yes No Yes NoAntipsychotics/Mood StabilizersCheck if takenWhen?Dosage?Did it help?Any side effects?Seroquel (quetiapine) Yes No Yes NoZyprexa (olanzapine) Yes No Yes NoGeodon (ziprasidone) Yes No Yes NoAbilify (aripiprazole) Yes No Yes NoClozaril (clozapine) Yes No Yes NoHaldol (haloperidol) Yes No Yes NoProlixin (fluphenazine) Yes No Yes NoSedative/HypnoticsCheck if takenWhen?Dosage?Did it help?Any side effects?Ambien (zolpidem) Yes No Yes NoSonata (zaleplon) Yes No Yes NoRestoril (temazepam) Yes No Yes NoRozerem (ramelteon) Yes No Yes NoDesyrel (trazodone) Yes No Yes No

ADHD MedicationsCheck if takenWhen?Dosage?Did it help?Any side effects?Adderall (amphetamine) Yes No Yes NoConcerta (methylphenidate) Yes No Yes NoRitalin (methylphenidate) Yes No Yes NoStrattera (atomoxetine) Yes No Yes NoAntianxiety MedicationsCheck if takenWhen?Dosage?Did it help?Any side effects?Xanax (alprazolam) Yes No Yes NoAtivan (lorazepam) Yes No Yes NoKlonopin (clonazepam) Yes No Yes NoValium (diazepam) Yes No Yes NoTranxene (clorazepate) Yes No Yes NoBuspar (buspirone) Yes No Yes NoOther Medications (specify)Check if takenWhen?Dosage?Did it help?Any side effects? Yes No Yes No Yes No Yes No Yes No Yes NoSUBSTANCE USE HISTORYSubstance Use Status: No history of abuse Active abuse Early full remission Early partial remission Sustained full remission Sustained partial remissionTreatment History: Outpatient Inpatient 12-step program Stopped on own Other:Substances Used (check all that apply)Ever Used?First use ageLast use ageCurrently Used? Alcohol Yes No Amphetamines/Speed Yes No Barbiturates Yes No Caffeine Yes No Cocaine Yes No Crack Cocaine Yes No Ecstasy Yes No Hallucinogens (LSD Yes No Heroin Yes No Inhalants Yes No Marijuana Yes No Methadone Yes No Methamphetamine Yes No Painkillers Yes No Nicotine/Tobacco Yes No PCP Yes No Tranquilizers Yes No Other: Yes NoFrequencyAmount

FAMILY HISTORYFamily of OriginPresent During ChildhoodBiological MotherPresententirechildhoodPresentpart ofchildhoodNotpresentat all Parents’ Current Marital Status:Childhood Family Experience: Married to each other Outstanding home environment Separated for years Normal home environment Divorced for years Chaotic home environment Mother remarried times Neglected Father remarried times Witnessed physical/verbal/sexualabuse towards othersBiological Father Adoptive Mother Adoptive Father Stepmother Mother involved with someoneStepfather Father involved with someoneBrother(s) Sister(s) Other: Mother deceased for yearsAge of patient at mother’s death: Father deceased for years Experienced physical/verbal/sexualabuse from othersAge of emancipation from home:Age of patient at father’s death:DEVELOPMENTAL HISTORYProblemsduring mother’spregnancy None German measles High blood pressure Emotional stress Drug use Kidney infection Bleeding Cigarette useBirth Normal deliveryBirth Weightlbs. oz.Infancy Feeding problems Difficult delivery Sleep problems Alcohol use Cesarean delivery Other: Complications: Toilet training problemsDelayed Development Milestones (check only those milestones that did not occur at an expected age) Sitting Speaking words Dressing self Riding bicycle Rolling over Speaking sentences Engaging peers Other: Standing Controlling bladder Tolerating separation Walking Controlling bowels Playing cooperatively German measles (age: ) Red measles (age: ) Lead poisoning (age: ) Mumps (age: ) Tuberculosis (age:) Mental retardation Allergies to: Rheumatic fever (age: Diphtheria (age:) Autism Feeding self Sleeping alone Riding tricycleChildhood Health Chickenpox (age: ) Scarlet fever (age: ) Pneumonia (age:) AsthmaEmotional/Behavioral Problems Drug use Alcohol abuse Fire setting Hyperactive Repeats words of others Not trustworthy Bizarre behavior Self-injurious threats Distrustful Extreme worrier Poor concentration Often sad Chronic lying Animal cruelty Hostile/angry mood Frequently tearful Self-injurious acts Breaks thingsSocial Interaction Normal social interaction Isolates self Dominates others Very shy Alienates self Associates with acting out peersIntellectual/Academic Functioning Normal intelligence High intelligence Underachieving Mild retardation Learning problems Moderate retardationCurrent or highest education level: Stealing Assaults others Indecisive Frequently daydreams Impulsive Other:) Whooping cough (age: Poliomyelitis (age:) Ear infections Violent temper Disobedient Immature Lack of attachment Easily distracted Inappropriate sex play Other: Authority conflicts Severe retardation Attention problems)

SOCIO-ECONOMIC HISTORYLiving Situation:Social Support System:Financial Situation: housing adequate supportive network no current financial problems homeless few friends large indebtedness housing overcrowded substance-use-based friends poverty or below-poverty income dependent on others for housing no friends impulsive spending housing dangerous/deteriorating distance from family of origin relationship conflicts over financesEmployment:Legal History:Military History: employed and satisfied no legal problems never in military employed but dissatisfied now on parole/probation served in military – no incident unemployed arrest(s) not substance-related served in military – with incident coworker conflicts arrest(s) substance related currently serving in military supervisor conflicts court ordered this treatment honorable discharge unstable work history jail/prison time(s) other type of discharge: living companions dysfunctional disabled:total time served:Sexual History:Cultural/Spiritual/Recreational History straight/heterosexual orientationCultural Identity (ethnicity, religion): lesbian/gay/homosexual orientationDescribe any cultural issues that contribute to current problem(s): bisexual orientationCurrently active in community/recreational activities? Yes No transsexualFormerly active in community/recreational activities? Yes No asexualCurrently engage in hobbies? Yes No unsure/questioning orientationCurrently participate in spiritual activities? Yes No currently sexually active currently sexually satisfiedRelationship History and Current Family: currently sexually dissatisfied married children living at home age first sex experience: divorced children living elsewhere age first pregnancy/fatherhood: single history of promiscuity age to widowed history of unsafe sex age to in a relationshipSave Form

Mental Health Intake Form (all information on this form is strictly confidential) Patient First Name: Patient Last Name: Name of Person completing form (if other than patient):