Adult Intake Form (Adult Intake) "*" indicates required fields Adult Intake Background Data This questionnaire is to gather important background information on you that will assist us in providing you high quality care. Please answer the following questions to the best of your ability. Date:* MM slash DD slash YYYY Name:* Date of Birth:* MM slash DD slash YYYY Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Phone:*Cell Phone:*Work Phone:*Email:* Gender Identity:* Male Female Transgender MTF FTM Gender Neutral Non-Binary Additional category (please specify):* Emergency Contact:* Relationship: Phone:*Form Completed by: (if someone other than patient) Name and Relationship: Presenting Problem1. Please tell us the purpose for which you are seeking outpatient mental health services: (please select all that apply)---------Select---------Anger ManagementAnxietyDepressionFear/PhobiasConfusionWork IssuesSleep ProblemsSexual ConcernsStressFamily/Marital ProblemsAlcohol/DrugsStressOther Mental Health Concerns (specify):Specify: Mental Health / Drug and Alcohol Treatment History*Name of Agency/TherapistDate/YearReason for Treatment Add RemovePlease Describe Your Experience With The Above Treatments If Applicable:Do You Currently Have A Psychiatrist? Yes No If Yes, What Is His/her Name: If Yes, Please complete the release of information form and include their name and addressSubstance Use History1. Do you currently drink alcohol? Yes No 2. Have you consumed alcohol in the past? Yes No 3. Are you or others concerned about your drinking Yes No 4. Do you currently use drugs? Yes No 5. Have you used drugs in the past Yes No 6. Are you or others concerned about your drug use? Yes No 7. Do you smoke cigarettes or use other forms of nicotine Yes No 8. If yes, how much per day?* 9. Are you interested in quitting? Yes No 10. Do you drink caffeine Yes No 11. If yes, how much per day? Medical History1. Do you have a family or primary care physician Yes No 2. May we contact him/her Yes No If Yes, Please complete the release of information form and include their name and addressName Address Street Address Have you had any of the following:1. Past or present medical illnesses? Yes No 2. Hospitalization/Operations Yes No If Yes, list year and type: 3. Head injuries or loss of consciousness Yes No If Yes, please describe: Are you currently taking any medications? (Including Psychiatric Prescriptions, Supplements, Herbs or Over-The-Counter Medications) Yes No If Yes, please list:*MedicationDosage/How Many Times Per Day Add RemoveFamily Medical History 1. Is there any history in your family of:Alcoholism/Alcohol Abuse Yes No If Yes, whom (please list) Drug Abuse or Dependence Yes No If Yes, whom (please list)* Heart Disease Yes No If Yes, whom (please list) Diabetes Yes No If Yes, whom (please list) High Blood Pressure Yes No If Yes, whom (please list)* Psychiatric Problems Yes No If Yes, whom (please list)* Suicide Attempts Yes No If Yes, whom (please list)* Family Background/Family of Origin1. How old is your father? If deceased, at what age? 2. Does/Did he have any health problems? Yes No If yes, describe:Quality of relationship with her: 3. How old is your mother? If deceased, at what age? Does/Did she have any health problems? Yes No If yes, describe:Quality of relationship with him: 4. If any, how old is/are your brother (s) and/or sister(s)? If deceased, at what age? Does/Did they have any health problems? Yes No If yes, describe: Quality of relationship with them: 5. Are your parent’s: Married Divorced Separated Never Married Remarried 6. What was it like for you growing up in your family? 7. How was discipline handled in your family? Current Family1. What is your current marital status: Married Divorced Never Married Separated Widowed Living Together 2. If applicable, how long have you been/were married? If applicable Name and age of spouse: 3. If applicable, how many times have you been married? 4. If not married, are you in a relationship? Yes No 5. Do you have any children? Yes No If yes, what are their ages? 6. Have family problems ever resulted in referral to County Children and Youth Services? Yes No 7. Who currently resides in your home? 8. If applicable, what is it like living in your current family or being in your current relationship? Developmental History1. Were there any problems prior to or during your birth that may have influenced your development? Yes No If yes, specify: 2. Were there any problems during your infancy or childhood that may have influenced your development? Yes No If yes, specify: 3. Have you ever had any history of physical, emotional or sexual abuse? Yes No If yes, specify: 4. Have you ever been witness to abuse Yes No 5. Have you had/have a partner who humiliates you or calls you names? Yes No 6. Have you had/have a partner that has been violent towards you? Yes No 7. Age of first sexual experience: 8. Sexual Orientation (circle one): Heterosexual Homosexual Bisexual Asexual 9. Do you have concerns regarding sexuality? Yes No If yes, explain: Social History1. What are your current hobbies or interests? 2. Are there any past hobbies or interests that you no longer are active in? Yes No If yes, what are they Check how you generally get along with other people: (check all that apply) Affectionate Aggressive Avoidant Fight/Argue Often Friendly Leader Outgoing Shy/Withdrawn Submissive Other Specify: Educational History1. What is your highest degree completed? Grade High School Diploma GED Some College College Grad Post Grad 2. How did you do in elementary school? A’s B’s C’s D’s F’s 3. If applicable, how did you do in high school? A’s B’s C’s D’s F’s 4. If applicable, how did you do in college? A’s B’s C’s D’s F’s 5. How well did you get along with your teachers at school? Good Fair Poor 6. Were there problem teachers? Yes No If yes, describe 7. How well did you get along with the other students in your class? Good Fair Poor Were there any problems with peers? Yes No Were you ever teased or bullied? Yes No If yes, describe: 8. Do you have any learning problems? Yes No If yes, describe: If yes, have you received treatment for them? Yes No Employment History1. What is your current employment status? Employed Unemployed Disabled Retired Other Other: If disabled, explain disability; 2. If employed, where are you employed? 3. What is your position? 4. How long have you been employed in your current position? 5. How many jobs have you had in the past? 6. What is the longest amount of time you have held a job? 7. If no employed, list your job skills: Military History (please skip if not applicable)1. What branch are/have you served? 2. Have you ever served in combat? Yes No 3. What is your discharge status? Legal History1. Are you currently involved in any legal proceedings? Yes No 1. Are you currently involved in any legal proceedings? Yes No 3. Are you currently on parole or probation? Probation Parole Neither If so, who is your contact person? May we contact them? Yes No If Yes, complete the release of information form and include their name, address and phone numberName Address Street Address Phone Number*4. Do you have any past legal involvement? Yes No Spiritual/Religious History1. How important to you are spiritual matters? Not Little Moderate Much 2. Are you affiliated with a spiritual or religious group? Yes No 3. Were you raised within a spiritual or religious group? Yes No 4. Would you like your spiritual/religious beliefs incorporated into the counseling? Yes No Cultural History1. With what race/ethnicity do you identify? 2. Are there important aspects (beliefs/practices) of your culture that we need to be aware of that will affect how we provide treatment? Specify:Treatment GoalsThe changes I want to make are: The most important reason I want to make these changes are: Other people who could help me in changing are: Ways they can help are: The things that could stand in my way of making changes are: My readiness for changes is best described as: (circle the number that best describes how ready you are) 1(Not Ready ) 2 3 4 5 6 7 8 9 10(Totally Ready) My confidence that I can achieve my goals is: (Circle the percentage that best describes your confidence in achieving your goals) 0% 25% 50% 75% 100% Signature of Patient: Date:* MM slash DD slash YYYY If Patient is unable to sign:Patient Representative (Print Name):* Patient Representaive Signature: Date:* MM slash DD slash YYYY Helping clients is our mission not only our profession!CommentsThis field is for validation purposes and should be left unchanged.
