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Grassroot Psychiatry Mental Health Clinic
Take care of your health and happiness with us
Primary Menu
Home
About
Team
Services
Anxieties
Depression
Panic Attacks
ADHD
Psychosis
PTSD
Addictions
Substance Abuse
Bipolar Disorders
Mood Disorders
Schizophrenia
ODD & DSDM
Policies
Forms
Contact
Intake Questionnaire For New Patients
Patient Name *
*
Phone Number *
*
Email Address *
*
Date:
*
Social Security Number:
*
Name:
*
Date of Birth:
*
Home Address:
*
City/State/Zip code:
*
Home Phone:
*
Cellular/Alternate Phone:
*
Marital Status:
Single
Married
Separated
Divorced
Remarried
Engaged
Widowed
Cohabiting
Partner’s Name:
*
Partner’s Age:
*
Partner’s Occupation:
*
01
02
03
04
05
06
01
02
03
04
05
06
In your own words, describe the current problems as you see them:
*
How long has this been going on?
*
What made you come in at this time?
*
What do you hope to gain from this evaluation and/or counseling?
*
If you had difficulties in the past, what have you done to cope? Was it helpful?
*
Please check any symptoms or experiences that you have had in the last month:
*
Difficulty falling asleep
Difficulty staying asleep
Not feeling rested in the morning
Difficulty getting out of bed
Average hours of sleep per night
Persistent loss of interest in previously enjoyed activities
Withdrawing from other people
Depressed Mood
Rapid mood changes
Anxiety
Frequent feelings of guilt
Difficulty leaving your home
Spending increased time alone
Feeling Numb
Irritability
Panic attacks
Avoiding people, places, activities or specific things
Fear of certain objects or situations (i.e., flying, heights, bugs)
Describe
Repetitive behaviors or mental acts (i.e., counting, checking doors, washing hands)
Outbursts of anger
Worthlessness
Sadness
Fear
Hopelessness
Helplessness
Feeling or acting like a different person
Changes in eating/appetite
Eating more
Voluntary vomiting
Excessive exercise to avoid weight gain
Eating less
Use of laxatives
Binge eating
Are you trying to lose weight?
Weight gain(lbs)
Weight loss(lbs)
Difficulty catching your breath
Unusual sweating
Increased energy
Tremor
Frequent worry
Racing thoughts
Increase muscle tension
Easily started, feeling “jumpy”
Decreased energy
Dizziness
Physical sensations others don’t have
Intrusive memories
Difficulty concentrating or thinking
Flashbacks
Thoughts about harming or killing yourself
Feeling as if you were outside yourself, detached, observing what you are doing
Feeling puzzled as to what is real and unreal
Persistent, repetitive, intrusive thoughts, impulses, or images
Unusual visual experiences such as flashes of light, shadows
Hear voices when no one else is present
Feeling that your thoughts are controlled or placed in your mind
Feeling that the television or the radio is communicating with you
Difficulty problem solving
Dependency on others
Inappropriate expression of anger
Difficulty or inability to say “no” to others
Sense of lack of control
Abusive relationship
Concerns about your sexuality
Large gaps in memory
Nightmares
Thoughts about harming or killing someone else
Difficulty meeting role expectations
Manipulation of others to fulfill your own desires
Self-mutilation/cutting
Ineffective communication
Decreased ability to handle stress
Difficulty expression emotions
Sexual Orientation:
Heterosexual
Hemosexual
Bisexual
I choose not to answer
Please describe any other symptoms or experiences you have had problems with:
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?
No
Yes
Name of therapist:
Reason for seeking help:
Dates of Treatment
Name of therapist:
Reason for seeking help:
Dates of Treatment
Name of therapist:
Reason for seeking help:
Dates of Treatment
Are you CURRENTLY taking PSYCHIATRIC medication?
No
Yes
Medication
Dosage
How long have you been taking it?
Has it been helpful?
Medication
Dosage
How long have you been taking it?
Has it been helpful?
Medication
Dosage
How long have you been taking it?
Has it been helpful?
Are you CURRENTLY taking NON-PSYCHIATRIC medication?
No
Yes
Medication
Dosage
How long have you been taking it?
Medication
Dosage
How long have you been taking it?
Medication
Dosage
How long have you been taking it?
Have you been on PSYCHIATRIC medication in the past?
No
Yes
Medication
Dosage
First/Last time you took it
Effect of Medication
Medication
Dosage
First/Last time you took it
Effect of Medication
Medication
Dosage
First/Last time you took it
Effect of Medication
Are you CURRENTLY taking NON-PSYCHIATRIC medication?
No
Yes
Hospital
Dates
Reason
Hospital
Dates
Reason
Hospital
Dates
Reason
Have you ever attempted suicide?
No
Yes
If YES, describe:
Are you CURRENTLY under treatment for any medical condition?
No
Yes
If YES, describe:
List any PRIOR illnesses, operations and accidents
Age:
Cause of death:
Living
Deceased
If deceased, HIS age at time of his death
YOUR age at time of his death
Occupation
Health
Frequency of contact with him
Are you/Have you been close to him?
Age:
Cause of death:
Living
Deceased
If deceased, HIS age at time of his death
YOUR age at time of his death
Occupation
Health
Frequency of contact with him
Are you/Have you been close to him?
Name
Sex
Age
Whereabouts
Are you close to him/her?
No
Yes
Name
Sex
Age
Whereabouts
Are you close to him/her?
No
Yes
Name
Sex
Age
Whereabouts
Are you close to him/her?
No
Yes
Name
Sex
Age
Whereabouts
Are you close to him/her?
No
Yes
During your childhood, did you live any significant period of time with anyone other than your natural parents?
No
Yes
Name
Relationship to you
Nervous Problems
Children
Brothers
Sisters
Father
Mother
Uncle/Aunt
Grandparents
Depression
Children
Brothers
Sisters
Father
Mother
Uncle/Aunt
Grandparents
Hyperactivity
Children
Brothers
Sisters
Father
Mother
Uncle/Aunt
Grandparents
Counseling
Children
Brothers
Sisters
Father
Mother
Uncle/Aunt
Grandparents
Psychiatric Medication
Children
Brothers
Sisters
Father
Mother
Uncle/Aunt
Grandparents
Psychiatric Hospitalization
Children
Brothers
Sisters
Father
Mother
Uncle/Aunt
Grandparents
Suicide Attempt
Children
Brothers
Sisters
Father
Mother
Uncle/Aunt
Grandparents
Death by Suicide
Children
Brothers
Sisters
Father
Mother
Uncle/Aunt
Grandparents
Drinking Problem
Children
Brothers
Sisters
Father
Mother
Uncle/Aunt
Grandparents
Have you been married previously?
When?
How long?
When?
How long?
Highest grade level completed
Degree obtained, if applicable
Degree obtained, if applicable
Did you have any disciplinary problems in school?
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?
What kinds of grades did you get in school?
If yes, please describe briefly:
What type of discharge (separation) did you get?
Are you currently employed?
If yes, employer’s name
What type of work do you do?
Type of Job
Dates
Reason for Leaving
Type of Job
Dates
Reason for Leaving
Type of Job
Dates
Reason for Leaving
Type of Job
Dates
Reason for Leaving
Have 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?
Verbally
Emotionally
Physically
Sexually
Neglected
Please describe
Do you drink alcohol?
If yes, age of first use
How much do you drink?
How often do you drink?
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?
Ever Used?
Age at 1st use
Time Since Last Use
Approx use in last 30 days
Ever Used?
Age at 1st use
Time Since Last Use
Approx use in last 30 days
Ever Used?
Age at 1st use
Time Since Last Use
Approx use in last 30 days
Ever Used?
Age at 1st use
Time Since Last Use
Approx use in last 30 days
Ever Used?
Age at 1st use
Time Since Last Use
Approx use in last 30 days
Ever Used?
Age at 1st use
Time Since Last Use
Approx use in last 30 days
Is there anything else you would like us to know about you?
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