(Adult) Mental Health Intake Form

Legal Name ______________________________ Date of Birth _____________

Address ____________________________________ Apt/Unit _____________
City _______________________ State _______ Zip Code __________
Phone #: Okay to send reminders?
________________________ Yes No
Email: Okay to send reminders?
____________________________ Yes No

Legal Gender Gender Identity Sexual Orientation

________________ _____________________ ___________________
Is there another name you’d like to go by? _____________________
Relationship Status: ______________________
Race: ________________ Ethnicity: ___________________
Emergency Contact Name Relationship Phone #
_______________________ _____________________ ____________________

How are you paying for your therapy? (If you are paying for insurance, you will be directed to
provide this information on a separate page)

How did you hear about our practice?

Presenting Problem
Please describe what is bringing you to therapy:

How long has this been a problem for you and what other help have you had with it?

How do your current difficulties affect you? (Work, school, family, relationships, personal well-
being, etc...)

What solutions to your problems have been most helpful up until now?

What would you like to gain from therapy?

How would things be different if the difficulties were resolved?

What support do you have in your life (Family / Friends / School / Work / Social activities, etc)?

Please check off any of the following problems you are experiencing
Aggressive behaviors Anger problems Changes in appetite Depressed mood
Difficulty concentrating Elevated mood Emotional trauma survivor
Fatigue/low energy Feelings of grief/loss Feelings of guilt Feeling hopeless
Feelings of shame Feelings of worthlessness Generalized anxiety
Highs/lows in mood Hyperactivity Impulsivity Irritability
Low mood Obsessive/compulsive behavior Panic attacks Phobias
Physical trauma survivor Self-harm behaviors/thoughts
Procrastination
Sexual dysfunction Sexual trauma survivor Significant weight gain/loss
Sleep problems Social isolation Substance abuse
Suicidal thoughts/ideations or attempts
 Psychiatric History
Please select all of the different types of psychiatric treatment you have had
Inpatient Hospitalization Residential Treatment (mental health or substance use)
Partial Hospitalization Program (PHP) Intensive Outpatient Program (IOP)
Outpatient Therapy (ex: individual therapy, Medication Management (Psychiatrist/Nurse
group therapy, marriage counseling, hypnosis Practitioner/PCP)
therapy, substance use treatment)
Other None
Are you currently taking any psychiatric medications? Yes No
If yes, please list all current medications along with their doses and the reason you are prescribed
them. (Write N/A if not applicable)

In the last month, have you wished you were dead or wished you could go to sleep and not wake up?
Yes No
Have you ever (at any point in your life) wished you were dead or wished you could go to sleep and
not wake up? Yes No
Have you actually had any thoughts of killing yourself? Yes No

Substance Use History

Do you now, or have you ever used any substances that were not prescribed to you by a physician?
Yes No
For each substance, identify if you have ever used it, age of first use and most recent use. **Only
consider substances that were NOT legally prescribed)
History of Age of Most
use first use recent use
Benzodiazepines (e.g. Xanax, Klonopin, etc…) Yes
No
Cannabis/Marijuana Yes
No
Cocaine Yes
No
Designer drugs (bath salts, herbal, steroids, cough syrup) Yes
No
Hallucinogens (LSD, PCP, mushrooms, etc.) Yes
 No
Opioids (fentanyl, heroin, narcotics, methadone, etc) Yes
No
Stimulants (crystal, speed, methamphetamine/amphetamines, Yes
etc.) No
Sedatives/hypnotics (Lunesta, Ambien, Valium, Phenobarb, Yes
etc.) No
Do you have any history of alcohol use? Yes No
If yes, how old were you when you first drank? __________________
When was your most recent drink? _________________
Have you ever been in treatment for your alcohol use? Yes No
If you checked off anything on the previous question, please share what was the reason for your
use?
Addicted Socialization Build confidence
To cope with my problems Escape Self-medication
Suicide/Self-harm attempt Other: ________________________________________________

Social & Developmental History

Pregnancy/Birth/Developmental
Description of Childhood
Normal Had basic needs met Placed in foster care Adopted
Involved abuse/neglect Witnessed or experienced traumatic events
Didn’t have basic needs met Witnessed fighting between parents/caregivers
A parent/caregiver died during your childhood Parent(s) present emotionally
Parents present physically
Comments:

Childhood Experiences Questionnaire

(Please answer the questions below only if you are comfortable doing so)
Did a parent, stepparent, or adult living in your home swear at you, insult
you, put you down, or act in a way that made you afraid that you might be
physically hurt?
Did a parent, stepparent, or adult living in your home push, grab, slap,
throw something at you, or hit you so hard that you had marks or were
injured?
Did an adult, relative, family friend, or stranger who was at least 5 years
older than you ever touch or fondle your body in a sexual way, make you
touch their body in a sexual way, attempted to have any type of sexual
intercourse with you?
Were any of your caregivers ever pushed, grabbed, slapped, have something
thrown at them, kicked, bitten, hit with a fist, hit with something hard,
repeatedly hit for over at least a few minutes, or ever threatened or hurt by
a knife or gun by another caregiver/adult in your life?
Was there a household member that was a problem drinker or alcoholic or a
household member who used street drugs?
Was there a household member who was depressed or mentally ill or a
household member who ever attempted or completed suicide?
Were your parents ever separated or divorced?
Was there household member who ever went to prison/jail?
Was there someone in your family who helped you feel important or
special?
Was there someone who made you feel loved?
Did people in your family look out for each other?
Was your family was a source of strength and support
Was there someone to take care of you, protect you, and take you to the
doctor if you needed it?
Was there ever a time you didn’t have enough to eat?
Was there ever a time your parents/guardians were too drunk or too high to
take care of you?
Education History
Highest level of education If in school, current grade Any school behavioral concerns?

Did you have any learning difficulties in school? If so, what where they? Yes No

Did you receive any accommodations? If yes, what were they? Yes No

If you attended college, did you graduate? If so, what was your degree in?

Employment History
Current employment status: Occupation:
Any concerns at work?

Current Living Situation

Live with parents/family Live alone College dorms With roommates
Homeless Living in shelter Military housing Prefer not to answer
Other:

Medical History
Family Medical History
Medical Conditions Parent 1 Parent 2 Sibling(s) Aunt Uncle Grandparents
Asthma/lung disease
Cancer
Cardiovascular disease
Diabetes
High blood pressure
Parent 1 Parent 2 Sibling(s) Aunt Uncle Grandparents
Neurological disorders
Seizures
Stroke
Thyroid disease/symptoms
Mental Health Conditions Parent 1 Parent 2 Sibling(s) Aunt Uncle Grandparents
ADHD
Anxiety
Bipolar disorder
Depression
Personality disorder(s)
Psychiatric hospitalizations
Schizophrenia
Self-harming
Substance use
Suicide attempts/thoughts
Please state who you considered: Parent 1 Parent 2:
Other conditions not listed above:

Personal Medical History

Current or past history of any of the following?
High blood pressure Heart problems Sexual functioning problems Cancer
Type 1 diabetes Type 2 diabetes Stroke history Allergies GI problems
Respiratory problems Other None
If other, please describe:

Do you have a primary care physician? Yes No

Who is your PCP if you have one? (Name/Practice Location)

Are you currently taking any non-psychiatric medications? Yes No

If yes, please list all current medications along with their doses and the reason you are prescribed
them. (Write N/A if not applicable)
 Assessment Measures
Depression and Anxiety Stress Scale (DASS-21)
Please read each statement and press a response that indicates how much the statement was true
to you over the PAST TWO WEEKS.
There are no right or wrong answers. Do not spend too much time on any statement.

Lovibond, S.H.; Lovibond, P.F. (1995). Manual for the Depression Anxiety Stress Scales (2nd ed.). Sydney: Psychology Foundation (Available from The
Psychology Foundation, Room 1005 Mathews Building, University of New South Wales, NSW 2052, Australia

Not true A little Fairly Very

true True True
I couldn’t seem to experience any positive feeling at all.
I found it difficult to work up the initiative to do things.
I felt that I had nothing to look forward to.
I felt downhearted and blue.
I was unable to become enthusiastic about anything.
I felt I wasn’t worth much as a person.
I felt that life was meaningless.

Not true A little Fairly Very

true True True
I found it hard to wind down.
I tended to over-react to situations.
I felt that I was using a lot of nervous energy.
I found myself getting agitated.
I found it difficult to relax.
I was intolerant of anything that kept me from getting on
with what I was doing.
I felt that I was rather touchy.

Not true A little Fairly Very

true True True
I was aware of dryness of my mouth.
I experienced breathing difficulty (e.g. excessively rapid
breathing, breathlessness in the absence of physical
exertion).
I experienced trembling (e.g. in the hands).
I was worried about situations in which I might panic and
make a fool of myself.
I felt I was close to panic.
I was aware of the action of my heart in the absence of
physical exertion (e.g. sense of heart rate increase, heart
missing a beat).
I felt scared without any good reason.
Patient Health Questionnaire-9 (PHQ-9)
Please read each statement and press a response that indicates how much the statement was true
to you over the PAST TWO WEEKS.

Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to
reproduce, translate, display or distribute.

Not at Several More than Nearly

all days half the days every day
Little interest or pleasure in doing things

Feeling down, depressed, or hopeless

Trouble falling or staying asleep, or sleeping too

much
Feeling tired or having little energy

Poor appetite or overeating

Feeling bad about yourself — or that you are a
failure or have let yourself or your family down
Trouble concentrating on things, such as
reading the newspaper or watching television
Moving or speaking so slowly that other people
could have noticed? Or the opposite — being
so fidgety or restless that you have been
moving around a lot more than usual
Thoughts that you would be better off dead or
of hurting yourself in some way
 Insurance Information
Primary Insurance Information
Insurance: Member ID# Group #:
________________________ _____________________ ____________
Client’s Relationship to Insured Insured’s Name (if not client)
______________________ __________________________
Insured’s DOB: ____________ Insured’s Sex: _____________
Insured’s Address/City/State/Zip: __________________________________________

Patient Health Questionnaire-9 (PHQ-9)

Please read each statement and press a response that indicates how much the statement was true
to you over the PAST TWO WEEKS.
Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to
reproduce, translate, display or distribute.

Not at Several More than Nearly

all days half the days every day
Little interest or pleasure in doing things

Feeling down, depressed, or hopeless

Trouble falling or staying asleep, or sleeping too

much
Feeling tired or having little energy

Poor appetite or overeating

Feeling bad about yourself — or that you are a
failure or have let yourself or your family down
Trouble concentrating on things, such as
reading the newspaper or watching television
Moving or speaking so slowly that other people
could have noticed? Or the opposite — being
so fidgety or restless that you have been
moving around a lot more than usual
Thoughts that you would be better off dead or
of hurting yourself in some way