Intake Form – GENTLE CARE

Mental Health Intake Form

(All Information on this form is strictly confidential)

Patient First Name:

Patient Last Name:

Name of Person completing form (if other than patient):

Date Completed:

Patient Date of Birth:

Primary Care Physician:

Physician Phone:

Current Symptoms Checklist (please check all appropriate columns)

MEDICAL HISTOTRY

Current Medications

Medication Name	Total Daily Dosage	Estimated Start Date

Describe current physical health:

GoodFairPoor

List any known allergies:

Past nonpsychiatric hospitalizations or surgeries:

Do you exercise regularly?

YesNo

Personal and Family Medical History (Have you or a family member ever had any of the following? If family, specify which family member)

EMOTIONAL/PSYCHIATRIC HISTORY

Prior Outpatient Treatment?
If yes, please describe:

YesNo

Reason	Dates Treated	By Whom

Prior Inpatient Treatment (for psychiatric, emotional, or substance abuse disorder)?
If yes, please describe:

YesNo

Reason	Date Hospitalized	Where

Family History (has anyone in your family ever been treated for any of the following)?

		Aunt	Uncle	Grandparent
Depression	FatherMotherBrotherSisterChildren	MaternalPaternal	MaternalPaternal	MaternalPaternal
Anxiety	FatherMotherBrotherSisterChildren	MaternalPaternal	MaternalPaternal	MaternalPaternal
Panic Attacks	FatherMotherBrotherSisterChildren	MaternalPaternal	MaternalPaternal	MaternalPaternal
Post Traumatic Stress	FatherMotherBrotherSisterChildren	MaternalPaternal	MaternalPaternal	MaternalPaternal
Bipolar Disorder/Manic Depression	FatherMotherBrotherSisterChildren	MaternalPaternal	MaternalPaternal	MaternalPaternal
Schizophrenia	FatherMotherBrotherSisterChildren	MaternalPaternal	MaternalPaternal	MaternalPaternal
Alcohol Problems	FatherMotherBrotherSisterChildren	MaternalPaternal	MaternalPaternal	MaternalPaternal
Drug Problems	FatherMotherBrotherSisterChildren	MaternalPaternal	MaternalPaternal	MaternalPaternal
ADHD	FatherMotherBrotherSisterChildren	MaternalPaternal	MaternalPaternal	MaternalPaternal
Suicide Attempts	FatherMotherBrotherSisterChildren	MaternalPaternal	MaternalPaternal	MaternalPaternal
Psychiatric Hospitalization	FatherMotherBrotherSisterChildren	MaternalPaternal	MaternalPaternal	MaternalPaternal

Past Psychiatric Medications (if you have ever taken any of the following medications, indicate the date, dosage, and how helpful they were)

Antidepressants	Check if taken	When?	Dosage?	Did it help?	Any side effects?
Prozac (fluoxetine)	if taken			YesNo	YesNo
Zoloft (sertraline)	if taken			YesNo	YesNo
Luvox (fluvoxamine)	if taken			YesNo	YesNo
Paxil (paroxetine)	if taken			YesNo	YesNo
Celexa (citalopram)	if taken			YesNo	YesNo
Effexor (venlafaxine)	if taken			YesNo	YesNo
Cymbalta (duloxetine)	if taken			YesNo	YesNo
Wellbutrin (bupropion)	if taken			YesNo	YesNo
Remeron (mirtazapine)	if taken			YesNo	YesNo
Serzone (nefazodone)	if taken			YesNo	YesNo
Anafranil (clomipramine)	if taken			YesNo	YesNo
Pamelor (nortrptyline)	if taken			YesNo	YesNo
Tofranil (imipramine)	if taken			YesNo	YesNo
Elavil (amitriptyline)	if taken			YesNo	YesNo
Pristiq (desvenlafaxin)	if taken			YesNo	YesNo
Desyrel (trazadone)	if taken			YesNo	YesNo
Viibryd (vilazodone)	if taken			YesNo	YesNo
Adapin (doxepin)	if taken			YesNo	YesNo
Asendin (amoxapine)	if taken			YesNo	YesNo
Ludiomil (maprotiline)	if taken			YesNo	YesNo
Norpramin (desipramine)	if taken			YesNo	YesNo
Surmontil (trimipramine)	if taken			YesNo	YesNo
Vivactil (protriptyline)	if taken			YesNo	YesNo
Antipsychotics/Mood Stabilizers	Check if taken	When?	Dosage?	Did it help?	Any side effects?
Seroquel (quetiapine)	if taken			YesNo	YesNo
Zyprexa (olanzapine)	if taken			YesNo	YesNo
Geodon (ziprasidone)	if taken			YesNo	YesNo
Abilify (aripiprazole)	if taken			YesNo	YesNo
Clozaril (clozapine)	if taken			YesNo	YesNo
Haldol (haloperidol)	if taken			YesNo	YesNo
Prolixin (fluphenazine)	if taken			YesNo	YesNo
Sedative/Hypnotics	Check if taken	When?	Dosage?	Did it help?	Any side effects?
Ambien (zolpidem)	if taken			YesNo	YesNo
Sonata (zaleplon)	if taken			YesNo	YesNo
Restoril (temazepam)	if taken			YesNo	YesNo
Rozerem (ramelteon)	if taken			YesNo	YesNo
Desyrel (trazodone)	if taken			YesNo	YesNo
ADHD Medications	Check if taken	When?	Dosage?	Did it help?	Any side effects?
Adderall (amphetamine)	if taken			YesNo	YesNo
Concerta (methylphenidate)	if taken			YesNo	YesNo
Ritalin (methylphenidate)	if taken			YesNo	YesNo
Strattera (atomoxetine)	if taken			YesNo	YesNo
Antianxiety Medications	Check if taken	When?	Dosage?	Did it help?	Any side effects?
Xanax (alprazolam)	if taken			YesNo	YesNo
Ativan (lorazepam)	if taken			YesNo	YesNo
Klonopin (clonazepam)	if taken			YesNo	YesNo
Valium (diazepam)	if taken			YesNo	YesNo
Tranxene (clorazepate)	if taken			YesNo	YesNo
Buspar (buspirone)	if taken			YesNo	YesNo
Other Medications (specify)	Check if taken	When?	Dosage?	Did it help?	Any side effects?
	if taken			YesNo	YesNo
	if taken			YesNo	YesNo
	if taken			YesNo	YesNo

SUBSTANCE USE HISTORY

Substance Use Status:

Treatment History:

Substances Used (check all that apply)

Ever Used?	First use age	Last use age	Currently Used?	Frequency	Amount
Alcohol			YesNo
Amphetamines/Speed			YesNo
Barbiturates			YesNo
Caffeine			YesNo
Cocaine			YesNo
Crack Cocaine			YesNo
Ecstasy			YesNo
Hallucinogens (LSD)			YesNo
Heroin			YesNo
Inhalants			YesNo
Marijuana			YesNo
Methadone			YesNo
Methamphetamine			YesNo
Painkillers			YesNo
Nicotine/Tobacco			YesNo
PCP			YesNo
Tranquilizers			YesNo
Other:			YesNo

FAMILY HISTORY

Family of Origin

Present During Childhood		Parents’ Current Marital Status:	Childhood Family Experience:
Biological Mother	Present entire childhoodPresent part of childhoodNot present at all	Married to each other Separated for years Divorced for years Mother remarried times Father remarried times Mother involved with someone Father-involved with someone Mother deceased for years Age of patient at mother’s death: Father deceased for years Age of patient at father’s death:	Outstanding home environmentNormal home environmentChaotic home environmentNeglectedWitnessed physical/verbal/sexualabuse towards othersExperienced physical/verbal/sexualabuse from others Age of emancipation from home:
Biological Father	Present entire childhoodPresent part of childhoodNot present at all
Adoptive Mother	Present entire childhoodPresent part of childhoodNot present at all
Adoptive Father	Present entire childhoodPresent part of childhoodNot present at all
Stepmother	Present entire childhoodPresent part of childhoodNot present at all
Stepfather	Present entire childhoodPresent part of childhoodNot present at all
Brother(s)	Present entire childhoodPresent part of childhoodNot present at all
Sister(s)	Present entire childhoodPresent part of childhoodNot present at all
Other:	Present entire childhoodPresent part of childhoodNot present at all

DEVELOPMENTAL HISTORY

Delayed Development Milestones (check only those milestones that did not occur at an expected age)

Childhood Health

Emotional/Behavioral Problems

Social Interaction

Intellectual/Academic Functioning

Current or highest education level:

SOCIO-ECONOMIC HISTORY

Living Situation:

Social Support System:

Financial Situation:

Employment:

Legal History:

no legal problemsnow on parole/probationarrest(s) not substance-relatedarrest(s) substance relatedcourt ordered this treatment
jail/prison time(s)
total time served:

Military History:

Sexual History:

Cultural/Spiritual/Recreational History:

Cultural Identity (ethnicity, religion):

Describe any cultural issues that contribute to current problem(s):

Currently active in community/recreational activities?

YesNo

Formerly active in community/recreational activities?

YesNo

Currently engage in hobbies?

YesNo

Currently participate in spiritual activities?

YesNo

Relationship History and Current Family:

Aggression	MildModerateSevere
Agitation	MildModerateSevere
Anger	MildModerateSevere
Anxiety	MildModerateSevere
Appetite change	MildModerateSevere
Change in libido	MildModerateSevere
Compulsions	MildModerateSevere
Crying/tearful	MildModerateSevere
Cyber addiction	MildModerateSevere
Delusions	MildModerateSevere
Depression	MildModerateSevere
Disorientation	MildModerateSevere
Difficulty getting out of bed	MildModerateSevere
Difficulty making decisions	MildModerateSevere
Distractibility	MildModerateSevere
Eating disorder	MildModerateSevere
Elevated mood	MildModerateSevere
Emotional trauma perpetrator	MildModerateSevere
Emotional trauma victim	MildModerateSevere
Excessive energy	MildModerateSevere
Fatigue	MildModerateSevere
Grief	MildModerateSevere
Guilt	MildModerateSevere
Gambling	MildModerateSevere
Hallucinations	MildModerateSevere
Hearing voices	MildModerateSevere
Heart palpitations	MildModerateSevere
Hopelessness	MildModerateSevere
Hyperactivity	MildModerateSevere
Impulsivity	MildModerateSevere
Irritability	MildModerateSevere
Judgment errors	MildModerateSevere
Loneliness	MildModerateSevere
Loss of interest in activities	MildModerateSevere
Memory impairment	MildModerateSevere
Mood swings	MildModerateSevere
Obsessions	MildModerateSevere
Oppositional behavior	MildModerateSevere
Panic attacks	MildModerateSevere
Paranoia	MildModerateSevere
Phobias/fear	MildModerateSevere
Physical trauma perpetrator	MildModerateSevere
Physical trauma victim	MildModerateSevere
Poor concentration	MildModerateSevere
Poor grooming	MildModerateSevere
Racing thoughts	MildModerateSevere
Recurring thoughts	MildModerateSevere
Self-mutilation	MildModerateSevere
Sexual addiction	MildModerateSevere
Sexual difficulties	MildModerateSevere
Sexual trauma perpetrator	MildModerateSevere
Sexual trauma victim	MildModerateSevere
Sleep problems	MildModerateSevere
Speech problems	MildModerateSevere
Social isolation	MildModerateSevere
Substance abuse	MildModerateSevere
Suicidal thoughts	MildModerateSevere
Worried	MildModerateSevere
Worthlessness	MildModerateSevere
Other:	MildModerateSevere
Other:	MildModerateSevere
Other:	MildModerateSevere

Alzheimer’s/Dementia	YouFamily
Anemia	YouFamily
Arthritis	YouFamily
Asthma	YouFamily
Behavioral problems	YouFamily
Birth defects	YouFamily
Cancer	YouFamily
Chronic Fatigue	YouFamily
Chronic Pain	YouFamily
Diabetes	YouFamily
Ear/Nose/Throat Problems	YouFamily
Eating Disorder	YouFamily
Emotional Problems	YouFamily
Endocrine/Hormone Problems	YouFamily
Epilepsy or Seizures	YouFamily
Eye Problems	YouFamily
Fibromyalgia	YouFamily
Gastrointestinal Problems	YouFamily
Genital/Gynecological Problems	YouFamily
Head Injury	YouFamily
Heart Disease	YouFamily
High Blood Pressure	YouFamily
High Cholesterol	YouFamily
HIV Positive or AIDS	YouFamily
Kidney Problems	YouFamily
Liver Problems/Hepatitis	YouFamily
Lung Disease	YouFamily
Mental Retardation	YouFamily
Migraine or Cluster Headaches	YouFamily
Neurological Problems	YouFamily
Skin Disease	YouFamily
Sleep Apnea	YouFamily
Stroke	YouFamily
Thyroid Disease	YouFamily
Tuberculosis	YouFamily
Urological Problems	YouFamily
Viral Illness/Herpes	YouFamily
Other:	YouFamily

Problems during mother’s pregnancy	NoneHigh blood pressureKidney infectionGerman measlesEmotional stressBleedingAlcohol useDrug useCigarette use Other:
Birth	Normal deliveryDifficult deliveryCesarean deliveryComplications
Birth Weight	lbs. oz.
Infancy	Feeding problemsSleep problemsToilet training problems

Mental Health Intake Form

Quick Links

Services

Contact Us