Mental Health Intake Form 
Please complete all information on this form.  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!  
Name______________________________________________________________Date___________________  Date of Birth ____________________          Place of Birth ________________________________________ 
Primary Care Physician_______________________________Primary Care Physician Phone ________________ 
Current Therapist/Counselor___________________________ Therapist's Phone_________________________  
Why are you seeking help?  1.________________________________________________________________________________________  2.________________________________________________________________________________________  3._______________________________________________________________________________________
What are your treatment goals?  1.________________________________________________________________________________________  2.________________________________________________________________________________________  3._______________________________________________________________________________________
Current Symptoms Checklist: (check once for any symptoms present, twice for major symptoms) 
(   ) Mood Swings                        (   ) Depressed Mood                  (   ) Racing Thoughts                  (   ) Excessive worry                     (   ) Unable to enjoy activities     (   ) Impulsivity                             (   ) Anxiety attacks                     (   ) Sleep pattern disturbance                      (   ) Increase risky behavior      (   ) Fears / Phobias                                  
(   ) Avoidance                             (   ) Loss of interest                       (   ) Increased libido                    (   ) Decreased libido                    (   ) Hallucinations                                   (   ) Concentration                        (   ) Decreased need for sleep       (   ) Suspiciousness                      (   ) Change in appetite                          
(   ) Excessive energy                    (   ) Excessive guilt                       (   ) Increased irritability           (   ) Anger/ Rage                         (   ) Fatigue                                   (   ) Crying spells                          (   ) Disconnection                      (   ) Confusion                              (   ) Forgetfulness                                            
Suicide Risk Assessment  
Have you ever had feelings or thoughts that you didn't want to live? ( ) Yes ( ) No.  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 ( ) No  
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? _________________________________________  On a scale of 1 to 10, (ten being strongest) how strong is your desire to kill yourself currently? ____________  Would anything make it better? ________________________________________________________________  Have you ever thought about how you would kill yourself? _________________________________________  Is the method you would use readily available? ___________________________________________________  Have you planned a time for this? ______________________________________________________________  Is there anything that would stop you from killing yourself? _________________________________________  Do you feel hopeless and/or worthless? _________________________________________________________  Have you ever tried to kill or harm yourself before? ________________________________________________ Do you have access to guns? If yes, please explain. ________________________________________________
Past Medical History:  
Allergies____________________________ Current Weight ____________ Height ____________  
List ALL current prescription medications and how often you take them: (if none, write none)  Medication Name Total Daily Dosage Estimated Start Date  
__________________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________  Current over-the-counter medications or supplements: ______________________________________________  __________________________________________________________________________________________  Current medical problems: ____________________________________________________________________  __________________________________________________________________________________________  Past medical problems, nonpsychiatric hospitalization, or surgeries: ___________________________________  __________________________________________________________________________________________  Do you have any concerns about your physical health that you would like to discuss with us? ( ) Yes ( ) No  
Date of last physical exam: ___________________________________________________________  
Personal and Family Medical History:
                                                            You              Family                        Family Member
Thyroid Disease ----------------------          (  )                 (  )                              ______________
Anemia--------------------------------            (  )                 (  )                              ______________
Liver Disease -------------------------           (  )                 (  )                              ______________
Chronic Fatigue -----------------------          (  )                 (  )                              ______________
Kidney Disease -----------------------           (  )                (  )                              ______________
Diabetes --------------------------------          (  )                (  )                              ______________
Asthma/respiratory problems ------            (  )                (  )                              ______________
Stomach or intestinal problems ---             (  )                (  )                              ______________
Cancer (type) ------------------------             (  )               (  )                              ______________
Fibromyalgia --------------------------           (  )               (  )                              ______________
Heart Disease -------------------------           (  )               (  )                              ______________
Epilepsy or seizures -----------------           (  )                (  )                              ______________
Chronic Pain -------------------------            (  )               (  )                              ______________
High Cholesterol --------------------            (  )               (  )                              ______________
High blood pressure------------------           (  )               (  )                              ______________
Head trauma --------------------------           (  )               (  )                              ______________
Liver problems -----------------------           (  )               (  )                              ______________
Other ___________________________________________________________  

Is there any additional personal or family medical history? ( ) Yes ( ) No If yes, please explain: __________________________________________________________________________________________  __________________________________________________________________________________________  
When your mother was pregnant with you, were there any complications during the pregnancy or birth?  __________________________________________________________________________________________  

Past Psychiatric History: 
Outpatient treatment (  ) Yes (  ) No 
If yes, please describe when, by whom, and nature of treatment. 
                Reason                                             Dates Treated                                                By Whom  
_________________________________________________________________________________________  _________________________________________________________________________________________  _________________________________________________________________________________________  Psychiatric Hospitalization ( ) Yes ( ) No 
If yes, describe for what reason, when and where.  
Reason                                                      Date                                                     Hospitalized Where  
__________________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________  
Past Psychiatric Medications: If you have ever taken any of the following medications, please indicate the  dates, dosage, and how helpful they were (if you can't remember all the details, just write in what you do  remember).  
                                                Dates         Dosage       Response / Side-Effects  
Antidepressants  
Prozac (fluoxetine) __________________________________________________________________________  Zoloft (sertraline) ___________________________________________________________________________  Luvox (fluvoxamine) ________________________________________________________________________  Paxil (paroxetine) ___________________________________________________________________________ Celexa (citalopram) _________________________________________________________________________ 
Lexapro (escitalopram) ______________________________________________________________________  Effexor (venlafaxine) ________________________________________________________________________  Cymbalta (duloxetine) _______________________________________________________________________  Wellbutrin (bupropion) ______________________________________________________________________  
Remeron (mirtazapine) ______________________________________________________________________ Serzone (nefazodone) _______________________________________________________________________  Anafranil (clomipramine) ____________________________________________________________________  Pamelor (nortrptyline) _______________________________________________________________________  Tofranil (imipramine) _______________________________________________________________________  Elavil (amitriptyline) ________________________________________________________________________  Other ____________________________________________________________________________________  
Mood Stabilizers  
Tegretol (carbamazepine)_____________________________________________________________________  Lithium___________________________________________________________________________________ Depakote (valproate) ________________________ _______________________________________________ Lamictal (lamotrigine) _______________________________________________________________________  Tegretol (carbamazepine) ____________________________________________________________________  Topamax (topiramate) _______________________________________________________________________  Other ____________________________________________________________________________________  
Antipsychotics/Mood Stabilizers
Seroquel (quetiapine) 
Zyprexa (olanzepine) ________________________________________________________________________  Geodon (ziprasidone) ________________________________________________________________________ Abilify (aripiprazole) ________________________________________________________________________  Clozaril (clozapine) _________________________________________________________________________ Haldol (haloperidol) ________________________________________________________________________  Prolixin (fluphenazine) ______________________________________________________________________ Risperdal (risperidone) ______________________________________________________________________  Other ____________________________________________________________________________________ Sedative/Hypnotics  
Ambien (zolpidem) _________________________________________________________________________  Sonata (zaleplon) ___________________________________________________________________________ Rozerem (ramelteon)________________________________________________________________________  Restoril (temazepam) ________________________________________________________________________  
Desyrel (trazodone) _________________________________________________________________________  Other _____________________________________________________________________________________ ADHD medications  
Adderall (amphetamine) _____________________________________________________________________ Concerta (methylphenidate) __________________________________________________________________  Ritalin (methylphenidate) ____________________________________________________________________ Strattera (atomoxetine) ______________________________________________________________________  Other ____________________________________________________________________________________  Antianxiety medications  
Xanax (alprazolam) ________________________________________________________________________  Ativan (lorazepam) _________________________________________________________________________  Klonopin (clonazepam) ______________________________________________________________________  Valium (diazepam) _________________________________________________________________________  Tranxene (clorazepate) ______________________________________________________________________  
Buspar (buspirone) __________________________________________________________________________  Other ____________________________________________________________________________________  
Medicinal Marijuana   
Condition(s):_______________________________________________________________________________
Dates: ________   Usage:_______________________________________________________________________ 
Response / Side-Effects: ______________________________________________________________________   

Exercise Level
Do you exercise regularly? (  ) Yes (  ) No  What type of exercise?__________________________________
How many days a week do you get exercise? ___________________________________________________  How much time each day do you exercise? ____________________________________________________  
Family Psychiatric History:  
Has anyone in your family been diagnosed or treated for:  
                                                                          Family Member(s)
Bipolar disorder (  ) Yes (  ) No                        ____________________________________________________                                                         
Personality Disorders (  ) Yes (  )                      __________________________________________________                                              
Schizophrenia (  ) Yes (  ) No                           ____________________________________________________                                            
Obsessive Compulsive Disorder ( ) Yes  ( )No_________________________________________________  
Depression (  ) Yes (   ) No                              ____________________________________________________                            
Post-traumatic stress ( ) Yes ( ) No                  ____________________________________________________      
Anxiety (  ) Yes (   ) No                                   ____________________________________________________                                                       
Alcohol Abuse ( ) Yes ( ) No                           ____________________________________________________      
Addiction (  ) Yes (  ) No                                 ____________________________________________________                                                             
Other Substance Abuse ( ) Yes ( ) No             ____________________________________________________      
Anger (  ) Yes (  ) No                                       ____________________________________________________ 
Violence ( ) Yes ( ) No                                     ____________________________________________________                                                          
Suicide (  ) Yes (  ) No                                     ____________________________________________________
Gaming / Gambling (  ) Yes (  ) No                _____________________________________________________            
Other (  )Yes  (  ) No  If yes, please describe: ____________________________________________________          
__________________________________________________________________________________________  
__________________________________________________________________________________________  

Substance Use:  
Have you ever been treated for alcohol or substance use or abuse? (  ) Yes (  ) No  
If yes, for which substances? __________________________________________________________________  If yes, where were you treated and when? ________________________________________________________  __________________________________________________________________________________________  How many days per week do you drink any alcohol? ____________  
What is the least number of drinks you will drink in a day? _______  
What is the most number of drinks you will drink in a day? _______  
In the past three months, what is the largest amount of alcoholic drinks you have consumed in one day? ______  Have you ever felt you ought to cut down on your drinking or substance  use? (  ) Yes (  ) No  
Have people annoyed you by criticizing your drinking or substance use? (  ) Yes (  ) No  
Have you ever felt bad or guilty about your drinking or substance use? (  ) Yes (  ) No  
Have you ever had a drink or used substances first thing in the morning to steady your nerves or to get rid of a  hangover? ( ) Yes ( ) No  
Do you think you may have a problem with alcohol or substance use? (  ) Yes (  ) No  
Have you used any recreational substances in the past 3 months? (  ) Yes (  ) No  
If yes, which ones? __________________________________________________________________________  Have you ever abused prescription medication? (  ) Yes (  ) No  
If yes, which ones and for how long? ____________________________________________________________  __________________________________________________________________________________________  
Check if you have ever tried the following:  
                          Yes     No            If yes, how long and when did you last use?
Crystal Methamphetamine  (   )    (   )            ___________________________________________
Cocaine                               (   )     (   )           ___________________________________________
Stimulants / Uppers            (   )     (   )           ___________________________________________
Tranquilizers / Downers     (   )     (   )            ____________________________________________
Heroin / Methadone            (   )    (   )            ____________________________________________
Hallucinogens                     (   )    (   )           _____________________________________________
Marijuana                            (   )    (   )          _____________________________________________ 
Ecstasy                                (   )    (   )          _____________________________________________
Inhalants                              (   )    (   )          _____________________________________________
Alcohol                                (   )    (   )          _____________________________________________
Other:  ____________________________________________________________  
How many caffeinated beverages do you drink a day? Coffee _______ Sodas ________ Tea ________  
Tobacco History: 
Have  you ever smoked cigarettes? (  ) Yes (  ) No  
Currently? (   ) Yes (   ) No  How many packs per day on average? ___________ How many years? _________  In the past? (  ) Yes (  ) No  How many years? ________ When did you quit? _____________  
Pipe, cigars, or chewing tobacco: Currently? (  ) Yes (  ) No In the past? (  ) Yes (  ) No 
What kind? __________ How often per day on average? ______ How many years? ____________  

Family Background and Childhood History:  
Were you adopted? (  ) Yes (  ) No  Where did you grow up? ________________________________________ 
 List your siblings and their ages: _______________________________________________________________  __________________________________________________________________________________________  What was your father's occupation? ____________________________________________________________  What was your mother's occupation? ___________________________________________________________  
Did your parents' divorce? (  ) Yes (  ) No   If so, how old were you when they divorced? __________________ 
If your parents divorced, who did you live with?___________________________________________________  Describe the divorce and it’s impact. ____________________________________________________________   
__________________________________________________________________________________________  __________________________________________________________________________________________  Describe your father and your relationship with him: _______________________________________________  __________________________________________________________________________________________  Describe your mother and your relationship with her: _______________________________________________  __________________________________________________________________________________________  How old were you when you left home? _________________________________________________________  Has anyone in your immediate family died? ______________________________________________________  Who and when? ____________________________________________________________________________  
Trauma History:  
Do you have a history of being abused emotionally, sexually, physically or by neglect?
(  ) Yes (  ) No (  ) Prefer not to answer
If Yes, please describe when, where and by whom: _________________________________________________________________________________________ 
__________________________________________________________________________________________   
Educational History:  
Highest Grade Completed? __________ Where? ________________________________________________ Did you attend college? ________ Where? ________________________Major? ________________________  What is your highest educational level or degree attained? __________________________________________  
Occupational History:  
Are you currently: ( ) Working ( ) Student ( ) Unemployed ( ) Disabled ( ) Retired  
How long in present position? _______________________________________________  
What is/was your occupation? ___________________________________________________  
Where do you work? _______________________________________________________  
Have you ever served in the military? _______ If so, what branch and when? ___________________________  
Are you currently serving in the military? (  ) Yes (  ) No 
If so, what branch and where? ___________________________  
 
Relationship History and Current Family:  
Relationship Status: (  ) Single  (  ) Married  (  ) Partnered (  ) Separated  (  ) Divorced
(  ) Widow (  ) Prefer not to answer 
(  ) Other relationship/ situationship___________________________________________________________  
How long? ________________
Are you sexually active? (  ) Yes (  ) No  (  ) Prefer not to answer 
Relationship Identity / structure :  
__________________________________________________________________________________________  
(eg: monogamous, consensual non-monogamy, polyamorous, questioning, etc.)
(  ) straight/heterosexual (   ) lesbian/gay/homosexual (  ) bisexual (  ) transsexual  
(  ) unsure/questioning (  ) asexual (  ) other (  ) prefer not to answer  
What is your spouse or partner’s occupation? _____________________________________________  Describe your relationship with your spouse or partner:  
__________________________________________________________________________________________  Have you had any prior marriages? ( ) Yes ( ) No. If so, how many? _____ How long? ___________________  
Do you have children? (  ) Yes (  ) No  If yes, list ages and gender: ___________________________________  __________________________________________________________________________________________  Describe your relationship with your children: ____________________________________________________  List everyone who currently lives with you: ______________________________________________________  __________________________________________________________________________________________  

Legal History: 
Do you have a criminal record? (  ) Yes  (  ) No  If yes, please provide a brief history:
__________________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________    
Do you have any pending legal problems? (  ) Yes (  ) No If yes, please provide a brief history:
__________________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________  ___________________________________________________________________
Spiritual Life: 
Do you belong to a particular religion or spiritual group? (  ) Yes (  ) No  
If yes, what is the level of your involvement? _____________________________  
Do you find your involvement helpful during this illness, or does the involvement make things more difficult or  stressful for you? (  ) more helpful (  ) stressful  
Is there anything else that you would like us to know?  
__________________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________  
__________________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________  

Signature_________________________________________________Date_____________________________  Guardian Signature (if under age 18) __________________________ Date _____________________________ Emergency Contact ________________________________________ Telephone # ______________________ 
For Office Use Only: 
Reviewed by ______________________________________________Date ____________________________  Reviewed by ______________________________________________Date ____________________________

PATIENT REGISTRATION 
(Please Print)                                                                                                           Today’s Date: ___/___/___

Patient's full name__________________________________________SS#______________________________________ Home address: _________________________________City_________________State_______Zip______________          Phone:________________Sex:___________Age:_______________Date of birth:________________________________
If Student, Place of Study: __________________________________________________________________________
Family Physician: ______________________________Referred By:___________________________________________
Emergency Contact: _______________________________ Phone:_____________________________________________

INSURED/RESPONSIBLE PARTY INFORMATION (Please complete this section regardless of insurance coverage)

Full Name of Insured: ___________________________Relationship: __________Occupation:_____________________
Address: ____________________________________________________ Phone: ______________________________
Employer and Address: _______________________________________________Phone: _______________________ Insured's SS #:___________________Driver's License #:_____________________ State:________________________ Name of spouse: _____________________Spouse's Employer: ______________Phone: ______________________ Insured's Primary Ins. Co.: ______________________________ID #:____________________Group:  _______________
Secondary Ins. Co.:  ___No ___ Yes;  Company:  __________________________________________________________
Job Related Injury-Workmens Comp. Co.:___No  ___ Yes; Company __________________________________________ 
OFFICE BILLING AND INSURANCE POLICY 
1. I authorize use of this form on all of my insurance submissions. 
2. I authorize the release of information to my insurance company(s). 
3. I understand that I am responsible for the full amount of my bill for services provided. 
4. I authorize direct payment to my service provider. 
5. I hereby permit a copy of this to be used in place of an original. 

Name: _______________________________________________ ID # _____________________________________
Signature: _______________________________________________ Date: ____________________________________

It is your responsibility to pay any deductible amount, co-pay, co-insurance amount or any other balance not paid by your insurance the day and time service is provided. There will be a $25.00 service charge on all returned checks. In the event that your account goes to collections, there will be a 20% collection fee added to your balance. 

Signature: _______________________________________________ Date: _____________________________________
CANCELLATION POLICY
If you must cancel or reschedule your appointment, we respectfully request at least 48 hours notice.  Cancellations or missed appointments without 48 hours notification will result in a cancellation fee of $100.00.
Signature: _______________________________________________ Date: ________________________

LIMITS ON PATIENT CONFIDENTIALITY 

We are required to disclose confidential information if any of the following conditions exist: 

1.	You are a danger to yourself or others.
2.	You seek treatment to avoid detection or apprehension or enable anyone to commit a crime.
3.	Your therapist was appointed by the courts to evaluate you. 
4.	Your contact with your therapist is for the purpose of determining sanity in a criminal proceeding.
5.	Your contact is for the purpose of establishing your competence. 
6.	The contact is one in which your psychotherapist must file a report to a public employer or as to information required to be recorded in a public office, if such a report or record is open to public inspection. 
7.	You are under the age of 16 years and are the victim of a crime. 
8.	You are a minor and your psychotherapist reasonably suspects you are the victim of child abuse.
9.	You are a person over the age of 65 and your psychotherapist believes you are the victim of physical abuse. Your therapist may disclose information if you are the victim of emotional abuse.
10.	You die and the communication is important to decide an issue concerning a deed or conveyance, will or other writing executed by you affecting as interest in property. 
11.	You file suit against your therapist for breach of duty or your therapist files suit against you. 
12.	You have filed suit against anyone and have claimed mental/emotional damages as part of the suit. 
13.	You waive your rights to privilege or give consent to limited disclosure by your therapist. 
14.	Your insurance company paying for services has the right to review all records. 
* If you have any questions about these limitations, please discuss them with your therapist. 
Signature: ____________________________________________      Date:________________________

I am consenting to my (or my dependent) receiving outpatient treatment. 
Signature: ______________________________________________  Date:_______________________

RELEASE OF INFORMATION 
I authorize________________________ to contact my primary care physician _____________________________
regarding an appointment being made for follow-up, as well as information pertaining to psychological and emotional function. 
Signature: ______________________________________________  Date:_________________________

Patient Health Questionnaire and General Anxiety Disorder  
(PHQ-9 and GAD-7)  
Date_______________ Patient Name:________________________________ Date of Birth: ______________  
Over the last 2 weeks, how often have you been bothered by any of the following problems?  Please circle your answers.  
PHQ-9 	Not at  all 	Several  days 	More than half  the days 	Nearly  
every day 	
1. Little interest or pleasure in doing things. 	0 	1 	2 	3 	
2. Feeling down, depressed, or hopeless. 	0 	1 	2 	3 	
3. Trouble falling or staying asleep, or sleeping too much. 	0 	1 	2 	3 	
4. Feeling tired or having little energy. 	0 	1 	2 	3 	
5. Poor appetite or overeating. 
  	0 	1 	2 	3 	
6. Feeling bad about yourself – or that you are a failure or have let  yourself or your family down. 	0 	1 	2 	3 	
7. Trouble concentrating on things, such as reading the  newspaper or watching television. 	0 	1 	2 	3 	
8. 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. 	0 	1 	2 	3 	
9. Thoughts that you would be better off dead, or of hurting  yourself in some way. 
Add the score for each column 	0 	1 	2 	3 	

Total Score (add your column scores): ______________  
If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or  
  
get along with other people? (Circle one)  
Not difficult at all             Somewhat difficult             Very Difficult                Extremely Difficult  ------------------------------------------------------------------------------------------------------------------------------------------------------------------ 
Over the last 2 weeks, how often have you been bothered by any of the following problems?  Please circle your answers.  
  
GAD-7 	Not at all  sure 	Several  
days 	Over half  
the days 	Nearly  
every day 	
1. Feeling nervous, anxious, or on edge. 	0 	1 	2 	3 	
2. Not being able to stop or control worrying. 	0 	1 	2 	3 	
3. Worrying too much about different things. 	0 	1 	2 	3 	
4. Trouble relaxing. 	0 	1 	2 	3 	
5. Being so restless that it’s hard to sit still. 	0 	1 	2 	3 	
6. Becoming easily annoyed or irritable. 	0 	1 	2 	3 	
7. Feeling afraid as if something awful might happen. 
  
Add the score for each column 	0 	1 	2 	3 	

Total Score (add your column scores): ______________  
If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or  
  
get along with other people? (Circle one)  
Not difficult at all             Somewhat difficult          Very Difficult          Extremely Difficult  
UHS Rev 4/2020  
  
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, 1999.