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Intake Questionnaire For New Patients (Adult)

PSY Family ServicesAdult Intake QuestionnairePage 1 of 8 Intake Questionnaire For New Patients (Adult) This Questionnaire is for the purpose of getting to know you better in order to provide the best possible mental health services. Please complete this form as honestly and completely as possible. All information that you provide us will be confidential as required by state and federal law. Date: Social Security Number: Name: Date of Birth: Age: Home Address: City/State/Zip code: Home Phone: Cellular/Alternate Phone: Marital Status:singlemarriedseparateddivorcedrem arriedengagedwidowedcohabitingIf applicable, please complete the following:Partner s Name: Partner s Age: Partner s Occupation: IF YOU HAVE CHILDREN PLEASE LIST THEIR NAMES AND AGES:#NameSexAge#NameSexAge142536 WHO CURRENTLY LIVES IN YOUR RESIDENCE ( adults and children):#NameRelationSexAge#NameRelati onSexAge142536In your own words, describethe current problems as you see them: How long has this been going on?

Adult Intake Questionnaire Page 8 of 8 The Holmes-Rahe Scale Read each of the events listed below, and check the box next to any even which has occurred in your life in the last two (2) years. There are no right or wrong answers. The aim is to identify which of these events you have experienced lately. Life Events Life Crisis Units

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Transcription of Intake Questionnaire For New Patients (Adult)

1 PSY Family ServicesAdult Intake QuestionnairePage 1 of 8 Intake Questionnaire For New Patients (Adult) This Questionnaire is for the purpose of getting to know you better in order to provide the best possible mental health services. Please complete this form as honestly and completely as possible. All information that you provide us will be confidential as required by state and federal law. Date: Social Security Number: Name: Date of Birth: Age: Home Address: City/State/Zip code: Home Phone: Cellular/Alternate Phone: Marital Status:singlemarriedseparateddivorcedrem arriedengagedwidowedcohabitingIf applicable, please complete the following:Partner s Name: Partner s Age: Partner s Occupation: IF YOU HAVE CHILDREN PLEASE LIST THEIR NAMES AND AGES:#NameSexAge#NameSexAge142536 WHO CURRENTLY LIVES IN YOUR RESIDENCE ( adults and children):#NameRelationSexAge#NameRelati onSexAge142536In your own words, describethe current problems as you see them: How long has this been going on?

2 What made you come in at this time? PSY Family ServicesAdult Intake QuestionnairePage 2 of 8 What do you hopeto gain from this evaluation and/or counseling? If you had difficulties in the past, what have you done to cope? Was it helpful? SymptomsPlease checkany symptoms or experiences that you have had in the last monthDifficulty falling asleepDifficulty staying asleepDifficulty getting out of bedNot feeling rested in the morningAverage hours of sleep per night: Persistent loss of interest in previously enjoyed activitiesWithdrawing from other peopleSpending increased time aloneDepressed MoodFeeling NumbRapid mood changesIrritabilityAnxietyPanic attacksFrequent feelings of guiltAvoiding people, places, activities or specific thingsDifficulty leaving your homeFear of certain objects or situations ( , flying, heights, bugs) Describe: Repetitive behaviors or mental acts ( , counting, checking doors, washing hands)Outbursts of angerWorthlessnessHopelessnessSadnessHel plessnessFearFeeling or acting like a different personChanges in eating/appetiteEating moreEating lessVoluntary vomitingUse of laxativesExcessive exercise to avoid weight gainBinge eatingAre you trying to lose weight?

3 Weight gain: lbsWeight loss: catching your breathIncrease muscle tensionUnusual sweatingEasily started, feeling jumpy Increased energyDecreased energyTremorDizzinessFrequent worryPhysical sensations others don t haveRacing thoughtsIntrusive memoriesPSY Family ServicesAdult Intake QuestionnairePage 3 of 8 Difficulty concentrating or thinkingLarge gaps in memoryFlashbacksNightmaresThoughts about harming or killing yourselfThoughts about harming or killing someone elseFeeling as if you were outside yourself, detached, observing what you are doingFeeling puzzled as to what is real and unrealPersistent, repetitive, intrusive thoughts, impulses, or imagesUnusual visual experiences such as flashes of light, shadowsHear voices when no one else is presentFeeling that your thoughts are controlled or placed in your mindFeeling that the television or the radio is communicating with youDifficulty problem solvingDifficulty meeting role expectationsDependency on othersManipulation of others to fulfill your own desiresInappropriate expression of angerSelf-mutilation/cuttingDifficulty or inability to say no to othersIneffective communicationSense of lack of controlDecreased ability to handle stressAbusive relationshipDifficulty expression emotionsConcerns about your sexualitySexual Orientation:HeterosexualHomosexualBisexu alI choose not to answerPlease describe any other symptoms or experiences you have had problems with:Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?

4 NoYesIf so:Name of therapist: Dates of TreatmentReason for seeking help: Name of therapist: Dates of TreatmentReason for seeking help: Name of therapist: Dates of TreatmentReason for seeking help: Are you CURRENTLY taking PSYCHIATRIC medication?NoYesIf YES, please list:MedicationDosageHow long have you been taking it?Has it been helpful?PSY Family ServicesAdult Intake QuestionnairePage 4 of 8 Are you CURRENTLY taking NON-PSYCHIATRIC medication?NoYesIf YES, please list:MedicationDosageHow long have you been taking it?Have you been on PSYCHIATRIC medicationin the past?NoYesIf YES, please list:MedicationDosageFirst/Last time you took itEffect of MedicationHave you been hospitalized for psychiatric reasons?NoYesIf YES, describe:HospitalDatesReasonHave you ever attempted suicide?NoYesIf YES, describe:MEDICAL HISTORYAre you CURRENTLY under treatment for any medical condition?NoYesIf YES, describe:List any PRIOR illnesses, operations and accidentsPSY Family ServicesAdult Intake QuestionnairePage 5 of 8 FAMILY HISTORYF ather:Age:LivingDeceasedCause of death:If deceased, HIS age at time of his deathYOUR age at time of his deathOccupation:Health:Frequency of contact with him: Are you/Have you been close to him?

5 Mother:Age:LivingDeceasedCause of death:If deceased, HER age at time of his deathYOUR age at time of his deathOccupation:Health:Frequency of contact with him: Are you/Have you been close to her? Brothers and SistersNameSexAgeWhereaboutsAre you close to him/her?NoYesNoYesNoYesNoYesDuring your childhood, didyou live any significant period of time with anyone other than your natural parents?NoYesIf so, please give the persona s name and relationship to youName: Relationship to you:Please place a check mark in the appropriate box if these are or have been present in your relativesChildrenBrothersSistersFatherMo therUncle/AuntGrandparentsNervous ProblemsDepressionHyperactivityCounselin gPsychiatric MedicationPsychiatric HospitalizationSuicide AttemptDeath by SuicideDrinking ProblemSOCIAL HISTORYPast Marital HistoryHave you been married previously?If Yes, please describeWhen?How long? When?How long? PSY Family ServicesAdult Intake QuestionnairePage 6 of 8 EducationHighest grade level completed: Degree obtained, if applicable: Did you have any disciplinary problems in school?

6 If yes, please explain: Were you considered hyperactive/ADHD in school? If yes, were/are you on any medication? If yes, were/are you on any medication? If so, which medication? What kinds of grades did you get in school?Have you served in the military? If yes, please describe briefly: What type of discharge (separation) did you get? EmploymentAre you currently employed? If yes, employer s name: What type of work do you do? Employment History (most recent first)Type of JobDatesReason for LeavingHave you been arrested? If yes, please describe: Do you have a religious affiliation? If yes, what is it? What kind of social activities do you participate in?Who do you turn to for help with your problems? Have you ever been abused?VerballyEmotionallyPhysicallySexu allyNeglectedPlease describe: PSY Family ServicesAdult Intake QuestionnairePage 7 of 8 SUBSTANCE ABUSEA lcoholDo you drink alcohol? If yes, age of first use How much do you drink? How often do you drink?

7 Have you ever passed out from drinking? How often? Have you ever blacked out from drinking? How often? Have you ever had the shakes ? How often? Have you ever felt you should cut down on your drinking/drug use? Have people annoyed you by criticizing your drinking/drug use? Have you ever felt bad or guilty about your drinking/drug use? Have you ever drank/used drugs in the morning to steady your nerves or relieve a hangover?Do you use tobacco? If yes, how often? Other Drugs:Please indicate for each drug listed belowDrugEver Used?Age at 1stuseTime Since Last UseApprox use in last 30 daysMarijuanaCocaineCrackHeroinMethamphe tamineEcstasyIs there anything else you would like us to know about you?PSY Family ServicesAdult Intake QuestionnairePage 8 of 8 The Holmes-Rahe ScaleRead each of the events listed below, and check the boxnext to any even which has occurred in your life in the last two (2) are no rightor wrong answers. The aim is to identify which of these events you have experienced EventsLife Crisis UnitsLife EventsLife Crisis UnitsDeath of Spouse100 Son or daughter leaving home29 Divorce73 Trouble with in-laws29 Marital Separation65 Outstanding personal achievement28 Gone to jail63 Spouse begins or stops work26 Death of close family member63 Begin or end school26 Personal injury or illness53 Change in living conditions25 Marriage50 Revisionin personal habits24 Fired at work47 Trouble with boss23 Marital reconciliation45 Change in work hours or conditions20 Retirement45 Change in residence20 Change in health of family member44 Change in schools20 Pregnancy40 Change in recreation19 Sexual Difficulties39 Change in church activities19 Gain of new family member39 Change in social activities18 Business readjustment39 Mortgage or loan less than $30.

8 00017 Change in financial state38 Change in sleeping habits16 Death of a close friend37 Change in number of family get-togethers15 Change to different line of work36 Change in eating habits15 Increase in arguments with spouse35 Vacation13 Mortgage over $100,00031 Christmas alone12 Foreclosure of mortgage or loan30 Minor violations of the law11 Change in responsibilities at work29 Your Total Score.


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