Patient Intake Form

The therapy and counseling work we do is unique to you, just as it is to each one of our clients. Before your first visit, we need to collect some general information from you.

GENERAL INFORMATION

Full Name*

Gender

Female

Male

Date of Birth

Month

Day

Year

Main Phone

Other Phone

Supportive Living Entity

Program Manager

Program Manager Phone

Program Manager Email

EMERGENCY CONTACT

Full Name

Phone

Relationship

INSURANCE INFORMATION

Primary Insurance

Policy Holder

Policy Holder DOB

Month

Day

Year

Relationship

Policy Holder Address

Policy Holder address

Country/Region

Address

City

Zip / Postal code

Policy Number

Group Number

SECONDARY INSURANCE INFORMATION

Secondary Insurance

Policy Holder

Policy Holder DOB

Month

Day

Year

Relationship

Policy Holder Address

Policy Number

Group Number

FINANCIALLY RESPONSIBLE PARTY

Full Name

Phone

PHARMACY

Name

Phone

Please, complete all information on this form and bring it to the first visit. It may seem long, but most of the questions require only a check, so it will go quickly. You may need to ask family members about the family history. Thank you.

Primary Care Physician (PCP)

PCP Phone

Are you receiving mental health treatment at this time?

Yes

If Yes, where?

What mental health services are you seeking?

Psychiatry

Therapy/Counseling

Why are you seeking mental health treatment at this time?

What do you hope to gain from mental health treatment? What would you like to be different?

What do you like about yourself? What are your personal strengths?

What are your interests and hobbies?

What is important to you?

What helps you to feel calm?

Current Symptoms Checklist: (check for any symptoms present, twice for major symptoms)

Depressed Mood

Unable to enjoy activities

Increased need for sleep

Decreased need for sleep

Loss of interest

Decrease in energy

Concentration/ forgetfulness

Change in appetite

Please Check All Symptoms That Apply

Excessive guilt

Fatigue

Decreased libido

Increased libido

Racing thoughts

Decrease in energy

Excessive energy

Increased irritability

Crying spells

Excessive worry

Anxiety attacks

Hallucinations

Suspiciousness

Suicidal thoughts

Violent thoughts

Other

Risky Behavior (explain)

Self-harm (explain)

PATIENT INTAKE FORM (continued)

Patient Full Name

Suicide Risk Assessment

Have you ever had feelings or thoughts that you didn’t want to live?

Yes

If Yes, please answer the following, If No, please skip to the next section.

Do you CURRENTLY feel that you don’t want to live?

Yes

How often do you have these thoughts?

When was the last time you had thoughts of dying?

Has anything happened recently to make you feel this way?

Would anything make it better?

Is the method you would use readily available?

Is there anything that would stop you from killing yourself?

Do you feel hopeless and/or worthless?

Have you ever tried to kill yourself before?

Do you have access to guns, weapons, medications, or anything you can hurt yourself with? If Yes, please explain.

Medical Information

Allergies

Current Weight

Current Height

List ALL current prescription medications and how often you take them. List Medication Name, Reason, Total Daily Dosage and Estimated Start Date.

A copy of your MAR is fine. Use the upload button to upload.

Current over-the-counter medications or supplements. List Medication/Supplement Name and Reason.

For women only: Are you currently pregnant or do you think you may be pregnant?

Yes

Do you have any concerns about your physical health that you would like to discuss with us?

Yes

Date and place of last physical exam.

Personal and Family Medical History/Status

Please check all of the following that apply to YOU.

Anemia

Asthma/respiratory problems

Cancer

Chronic pain

Diabetes

Epilepsy or seizures

Fibromyalgia

Head trauma/ Traumatic Brain Injury

Heart Disease

High blood pressure

High cholesterol

Intellectual or Developmental Disability

Kidney Disease

Liver Disease/problems

Stomach or intestinal problems

Thyroid Disease

Other

Please check all of the following that apply to a family member.

Anemia

Asthma/respiratory problems

Cancer

Chronic pain

Diabetes

Epilepsy or seizures

Fibromyalgia

Head trauma/ Traumatic Brain Injury

Heart Disease

High blood pressure

High cholesterol

Intellectual or Developmental Disability

Kidney Disease

Liver Disease/problems

Stomach or intestinal problems

Thyroid Disease

Other

Which family member(s) do the above apply to?

List all past medical problems, non-psychiatric hospitalizations or surgeries:

Have you ever had an EKG?

Yes

If yes, was the EKG

Normal

Abnormal

Unknown

Not Applicable

Have you participated in outpatient mental health treatment before? If Yes, describe. List reasons for outpatient mental health treatment, Dates Treated, By Whom (Where), and Was it a positive or negative experience?

Have you been hospitalized for mental health treatment before? If Yes, describe. List reasons for inpatient mental health treatment, Dates Treated, By Whom (Where), and Was it a positive or negative experience?

Past psychotropic medications: If you have ever taken any of the following medications please check.

Antidepressants:

Anafranil (clomipramine)

Celexa (citalopram)

Cymbalta (duloxetine)

Effexor (venlafaxine)

Elavil (amitriptyline)

Lexapro (escitalopram)

Luvox (fluvoxamine)

Pamelor (nortrptyline)

Paxil (paroxetine)

Prozac (fluoxetine)

Remeron (mirtazapine)

Serzone (nefazodone)

Tofranil (imipramine)

Wellbutrin (bupropion)

Zoloft (sertraline)

Other

If you have ever taken any of the above medications, please, indicate the dates and how helpful the medication was. (If you can’t remember all the details just write in what you do remember.)

Mood Stabilizers:

Depakote (valproate)

Lamictal (lamotrigine)

Lithium

Tegretol (carbamazepine)

Topamax (topiramate)

Other

If you have ever taken any of the above medications, please, indicate the dates and how helpful the medication was. (If you can’t remember all the details just write in what you do remember.)

Antipsychotics/Mood Stabilizers:

Abilify (aripiprazole)

Clozaril (clozapine)

Geodon (ziprasidone)

Haldol (haloperidol)

Prolixin (fluphenazine)

Risperdal (risperidone)

Seroquel (quetiapine)

Zyprexa (olanzepine)

Other

If you have ever taken any of the above medications, please, indicate the dates and how helpful the medication was. (If you can’t remember all the details just write in what you do remember.)

Sedative/Hypnotics:

Ambien (zolpidem)

Desyrel (trazaodone)

Restoril (temazepam)

Rozerem (ramelteon)

Sonata (zaleplon)

Other

If you have ever taken any of the above medications, please, indicate the dates and how helpful the medication was. (If you can’t remember all the details just write in what you do remember.)

ADHD medications:

Adderall (amphetamine)

Concerta (methylphenidate)

Ritalin (methylphenidate)

Strattera (atomoxetine)

Other

If you have ever taken any of the above medications, please, indicate the dates and how helpful the medication was. (If you can’t remember all the details just write in what you do remember.)

Anti-anxiety medications:

Ativan (lorazepam)

Buspar (buspirone)

Klonopin (clonazepam)

Tranxene (clorazepate)

Xanax (alprazolam)

Valium (diazepam)

Other

If you have ever taken any of the above medications, please, indicate the dates and how helpful the medication was. (If you can’t remember all the details just write in what you do remember.)

Have you had treatment for alcohol or drug abuse? If Yes, which substances?

In the past 3 months, what is the largest amount of alcohol you have consumed in one day?

Have you used street drugs in the past 3 months? If Yes, which drugs?

Have you ever abused prescription medication? If Yes, which one(s) and for how long?

Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?

Yes

Has anyone said that you may have a problem with alcohol or drug use?

Yes

Do you think you may have a problem with alcohol or drug use?

Yes

Check all that you have ever tried:

Alcohol

Cocaine

Ecstasy

Heroin

LSD or hallucinogens

Marijuana

Methadone

Methamphetamine

Pain killers (not as prescribed)

Stimulant (pills)

Tranquilizer/ sleeping pills

Other

For the ones checked above, list how long and when was your last use.

Patient Full Name*

Tobacco and Caffeine

How many caffeinated beverages do you drink a day?

Coffee

Sodas

Tea

Energy Drinks

Do you currently smoke? If Yes, how many years?

Check all that you currently use:

Pipe

Cigars

Chewing Tobacco

None

Other

What kind do you use? How many years of use for each kind?

Family Background and Childhood History

Ethnic/cultural background:

Were you adopted?

Yes

Where did you grow up?

Who did you live with when you were a child?

What was your relationship like with the person or people who raised you?

How old were you when you left home?

Trauma History or Trauma Witnessed

Check all that you have experienced.

Physical Abuse

Emotional Abuse

Neglect

Sexual Abuse as Victim

Sexual Abuse as Perpetrator

Death in immediate family

Distressful or Painful events that still bother you

Other

Please, elaborate on any checked responses.

Educational History

What is the highest grade completed and from where did you complete this highest grade?

Did you participate in Special Education? If yes, please describe.

Completed some college or vocational training? If yes, please describe.

Completed four-year degree? If yes, please describe.

Completed graduate degree? If yes, please describe.

Reading Level

Cannot read

Can read some

Can read very well

Writing Level

Cannot write

Can write some

Can write very well

Do you need assistive technology? If yes, please describe.

Do you need an interpreter (sign language or language other than English)?

Occupational History

Are you currently?

Working

Unemployed, looking for work

Unemployed, not looking for work

Disabled

Retired

Student

Where do you work? For how long?

What kind of work have you done in the past?

Have you ever served in the military? If yes, describe.

Relationships and Current Living Situation

Are you currently?

Single

Married

Divorced

Widowed

Partnered

How long have you been married or partnered?

How long have you been divorced or widowed?

If you are not married or partnered, are you currently in a relationship?

Yes

Describe your relationship with your spouse/significant other.

How would you identify your sexual orientation?

straight/heterosexual

lesbian/gay/homosexual

bisexual

transgender

unsure/ questioning

asexual

prefer not to answer

Other

Do you have children? If yes, how many?

Where do you live?

alone, without paid supports

alone, with paid supports

supported housing/living

with family/ significant other/ natural supports

Other

Who lives with you? List name and relationship.

Legal

Have you ever been arrested? If yes, describe.

Do you have any pending legal problems? If yes, describe.

Spiritual/Religious

What is your religious preference?

Do you find your involvement helpful during this time in your life?

Yes

How does practicing your religion help you?

Is there anything else you would like us to know?

Who helped you to complete this form?

Signature of Patient or Guardian

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Date

Month

Day

Year

Welcome to Touching Hearts Home Health Care Dedicated to Providing the Best In-Home Health Care

PATIENT INTAKE FORM

GENERAL INFORMATION

EMERGENCY CONTACT

INSURANCE INFORMATION

SECONDARY INSURANCE INFORMATION

FINANCIALLY RESPONSIBLE PARTY

PHARMACY

PATIENT INTAKE FORM (continued)

Suicide Risk Assessment

Medical Information

Personal and Family Medical History/Status

Tobacco and Caffeine

Family Background and Childhood History

Trauma History or Trauma Witnessed

Educational History

Occupational History

Relationships and Current Living Situation

Legal

Spiritual/Religious

Welcome to
Touching Hearts Home Health Care
Dedicated to Providing the Best In-Home Health Care