Behavior Health Services Mental Health Intake Form

Behavior Health Services Mental Health Intake Form

If you need any help completing this form, please inform the front desk or your therapist and we will be happy to help.
First Name   Last Name   Date

Last Name at Birth (If different)    Date of Birth  DOB

Who referred you?

Client Phone Number   Area Code   Phone Number

Do we have permission to leave a message at this phone number?
   Yes   No

Primary Care Physician:      Location:

Date of last physician exam:   Date

Emergency Contact: First Name   Last Name
Emergency Contact Phone Number:   Area Code   Phone Number
Relationship:
What are the problem(s) for which you are seeking help
What are your treatment goals?
Current Symptoms Checklist: (Check all that apply)

Depressed moodUnable to enjoy activitiesSleep pattern disturbanceAngerHallucinationsDecreased need for sleepChange in appetiteIncreased irritabilityConcentration/ForgetfulnessSocial Withdrawal/IsolationRacing ThougtsImpulsivityIncreased risky behaviorAvoidanceDecreased libidoExcessive energyFatigueSuicidal IdeationMemory ProblemsIncreased LibidoExcessive WorryAnxiety AttacksSuspiciousnessLoss of interestCrying SpellsExcessive GuiltHopelessnessWeight Gain/LossGriefCompulsionsOther Symptoms
Suicide Risk Assessment
Have you ever had feelings or thoughts of suicide?    Yes   No

Do you currently feel like committing suicide?       Yes   No

How often do you have thoughts of suicide?

Have you ever tried to kill or harm yourself in the past?   Yes   No
Past Medical History:
List ALL current prescriptions and over the counter medications in the field below:
Past Psychiatric History:
Outpatient Treatment

YesNo
If yes, describe for what reason and when.
Psychiatric Hospitalization

YesNo
Has anyone in your family been diagnosed with or treated for any mental health disorder?
Substance Abuse
Have you ever been treated for alcohol or drug abuse?

YesNo
If yes, for what substance(s), and when were you treated?
Do you drink alcohol? Yes No
How much/often?
Do you use ANY other drugs recreationally (Not prescribed by a doctor)? How often?
Family Background and Childhood History:
Did your parents' divorce?   Type option 1   No
If yes, how old were you when they divorced?
Were any of your parents incarcerated while you were growing up?
Trauma History:
Do you have a history of being abused emotionally, sexually, physically, or by neglect?
Yes   No
Please list when and by whom:

Do you experience any symptoms directly as a result of past traumas? (Check all that apply)
Hypervigilance   Difficulty Sleeping   Feeling numb or detached   Feelings of reliving the events   Distress remembering the events   Easily startled   Difficulty concentrating   Blaming self for events    Avoiding certain people, places, activities    Disturbing memories, thoughts, or imagesQuick to anger   Nightmares
Educational History
What is your highest education level or degree attained?
Occupational History
Currently I am:

Full-timePart-timeStudentUnemployedDisabledRetiredHomemakerSheltered/Non-Competitive Employment
Current source of income: blanks . Monthly amount of income: blank

Have you ever served in the military? Type option 1 Type option 2
If yes, how long?
Relationship History and Current Family
Type a question

MarriedDivorcedSingleWidowedIn a Relationship
If currently in a relationship, how long have you been in this relationship?
How would you identify your sexual orientation?
Do you have children?

YesNo
If yes, please list names, ages and gender:
Legal History
Have you ever been arrested

YesNo
If yes, how many times?
Have you ever had a DUI

YesNo
If you answered yes to having a DUI, how many? blanks
Please provide State Identification Number: blank
Do you have any current legal problems?

YesNo
Cultural and Spiritual Life
What ethnicity do you identify with?
If you have an Oregon Tribal Affiliation please state which one:
Do you belong to a particular religion or spiritual group?

YesNo
What are your favorite hobbies/activities?
What are your strengths? What do you most like about yourself?
Is there anything else that you would like us to know?
Signature: Signature Date
Guardian Signature (if under age 14) Signature Date
Should be Empty:

Behavior Health Services Mental Health Intake Form

Substance Abuse

Family Background and Childhood History:

Trauma History:

Educational History

Occupational History

Relationship History and Current Family

Legal History

Cultural and Spiritual Life