Department of Professional Psychology

Bahria University Lahore Campus

Intake Form
Date: ________________
Name: __________________________ Sex: Male/ Female
Date of Birth: ____________________ Age: _____________________
Marital Status: S M D W Sep
Permanent Address: _____________________________________________________________
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Phone #: ___________________________ Education: ________________________________
Occupation: ________________________
Father’s Information:
Name: ________________________________ Age: __________________________
Education: _____________________________ Occupation: ____________________
Mother’s Information:
Name: ________________________________ Age: __________________________
Education: _____________________________ Occupation: ____________________
Spouse’s Information
Name: ________________________________ Age: __________________________
Education: _____________________________ Occupation: ____________________
Children Information
Number of Children: ___________________
Family Information:
Head of Family: _________________________ Earning Members: _________________
Income Group: __________________________ Heritage: ________________________
Languages: Urdu / Punjabi / English / Pashtu / Sindhi / Balochi / Saraiki / Hindko / Other: _____
Patient’s Appearance: __________________________________________________________
Informant’s Information:
Informant’s Name: _______________________ Relationship: _____________________
Informant’s Number: _____________________ Informant’s Address: _______________
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Referred to: _____________________________ Referral Date: ____________________
Intake By: ______________________________ Termination Date: ________________

Presenting Complaints: __________________________________________________________

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Additional Information: __________________________________________________________

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Tentative Diagnosis: ____________________________________________________________

 Department of Professional Psychology
Bahria University Lahore Campus
CASE HISTORY SHEET
Patient’s Name: ___________________________ Father’s Name: ______________________
Therapist: ________________________________ Date: ______________________________

Presenting Problems (nature of problems, precipitating event, patient’s feelings and thoughts
about the problem) ______________________________________________________________
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History of Problems (duration of present problem, changes in nature, intensity, and/or

frequency of problem over time, prodromal manifestations, other past problems of a
psychological nature, No. of attacks)
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Prior Treatment (Details of treatment sought for presenting problems and from whom: When
the treatment was sought? Duration of treatment? Nature of the treatment methods: Name,
Dosage: ECT, Faith Healing, etc. response to the treatment including adverse reactions or side
effects if any):
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Medical History (most recent physical exam: date and results; current medications; health
condition since childhood including details of serious illness/disabilities suffered and surgery
undergone; eating and sleeping if remarkable and any change of same; use of stimulants, alcohol
and drug): _____________________________________________________________________
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Family History (migrations, births, marriages serious illnesses, deaths, jobs of earning members,
relationship with family members): _________________________________________________
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Family Psychopathology (nature, history and treatment of mental disorders on members of the
patient’s family: ________________________________________________________________
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School History (marks/divisions obtained, school changes, school problems, relationships with
peers and teachers, extra-curricular activities): ________________________________________
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Work history (nature of jobs held, reasons for job changes, and relationships with juniors,
colleagues and bosses):
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History of Friendships (nature and extent of relationships, recreational activities, degree of
religiosity, sexual history – premarital, marital and extramarital sexual relationships): _________
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Orientation: (time, place and person): ______________________________________________
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Somatoform (conversion, hypochondriasis, and other somatic complaints: _________________

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Space for additional Information: __________________________________________________

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Tentative Diagnosis: ___________________________________ Date: _______________

Final Diagnosis: ______________________________________ Date: _______________
 Department of Professional Psychology
Bahria University Lahore Campus
MENTAL STATUS SHEET

Orientation (Date, Time, Place): Intact Broken

Sleep: Intact Broken Insomnia Nightmares Sleepwalking

Night terrors other: __________________________________________________

Attention (Concentration, Memory): Intact Broken

Other: ______________________________________________________________

Perception: Intact Illusions Hallucinations (Auditory, Visual, Tactile, Somatic,

Olfactory)

Thoughts Patterns: Intact Suspiciousness Delusions

Loosening of Associations
Other: ______________________________________________________________

Affect: Crying Spells Depressive Guilt Feelings Suicidal Hostility

Excitement Grandiosity Blunted Effects

Other: _________________________________________________________

Speech: Mute Talkative Abusive

Other: ______________________________________________________________

Motor: Restless Assaultive Destructive Excited Motor

Retardation

Anxiety: Tension Nervousness Phobias Obsessions

Compulsions Other: _______________________________________________

Mannerisms and Posturing: Unusual gestures Preservative movements

Other: ______________________________________________________________

Psychosomatic: Obesity Headaches Painful Menstruation Asthma

Skin Disorders Nausea Vomiting Vertigo Anorexia

Addictions: Narcotics Use Smoking Chewing Tobacco Alcohol Use

Gambling

Other: ____________________________________________________________

Interview Behavior: Open Secretive Anxious Relaxed Withdrawn

Timid Aggressive Complaint Cooperative

Other: ____________________________________________________________

Strengths: Degrees of Insight Motivation Intellect Level Mitigating

Circumstances

Other: ____________________________________________________________

Psychosexual: Gender Identity Paraphilia Psychedelia dysfunctions

Intact

Personality Traits: Paranoid Schizoid Schizotypal Antisocial

Borderline Histrionic Narcissistic Avoidant Dependent

Passive Aggressive OCD

Other: ____________________________________________________________