INTAKE FORM

INTAKE FORM

Identifying Info
Name *

First Name Middle Initial Last Name
Date of Birth *

Month Day Year
Date
Age *
Sex Assigned at Birth *
Gender Identity *
Gender Pronouns
Sexual Orientation *
Ethnic Background *
e.g. Irish, Polish, German, African American
Who resides with you?
How did you hear about Dr. Grant?
Phone Number *

Area Code Phone Number
May Dr. Grant or his associates call, leave a VM and/or text? *
CURRENT ISSUE
Briefly explain why you are seeking services at this time: *
Have you participated in psychotherapy before? *
If so, with whom, where, and dates?
And what were you seeking services for?
Have you ever been treated by a psychiatrist or NP? *
If so, with whom and where?
What were you seeking services for?
Current Psychiatrist or NP's name

First Name Last Name
Address of Psychiatrist or NP

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number of Psychiatrist or NP

Area Code Phone Number
Fax Number of Psychiatrist or NP

Area Code Phone Number
Has anyone in your family suffered from a mental health or substance abuse issue? *
If so, whom?
What has your experience been like with healthcare providers?
SYMPTOM CHECKLIST

Check ALL that apply
*
MEDICAL HISTORY
Primary Care Physician's Name

First Name Last Name
Date of last physical exam

Month Day Year
Date
Address of PCP

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number of PCP

Area Code Phone Number
Current Medical Problems
Past Surgical History & Hospitalization(s)
MEDICATIONS/OTC

Include Supplements/Herbs etc.
ADDITIONAL MEDICAL INFO
Have you ever taken psychotropic medication in the past? *
If so, please describe
Do you or have you participated in Complimentary and Alternative Treatments to Medicine (CAMS)? *
(e.g. MASSAGE THERAPY, AROMATHERAPY, HERBAL MEDICINE, ACUPUNCTURE, MEDITATION, YOGA, MANIPULATIVE/BODY BASED PRACTICES, DIETARY SUPPLEMENTS, ENERGY THERAPIES)
If so, please describe
Describe your exercise habits *
How would you describe your overall health? *
ALCOHOL & DRUG USE
Age of your first intoxication *
Do you believe you have a current problem with alcohol or drugs
Have you ever sought treatment for an alcohol or drug problem?
If so, please describe dates, locations and length of treatment
Do you smoke cigarettes, cigars, use pipes or chew tobacco?
If so, please describe use
Do you consume caffeine?
If so, please describe your use
EDUCATION
Name of High School
Highest Grade Completed
Did you attend trade/technical school or college
Name of trade/school
Did you graduate?
Name of trade/school
Did you graduate?
Name of trade/school
Did you graduate?
If not, please explain
Did you participate in any extracurricular activities while in school/college?
If so, please describe
EMPLOYMENT
Current Employer
Title/Occupation
State Date

Month Day Year
Date
Current Employer
Title/Occupation
Start Date

Month Day Year
Date
Have you held other jobs *
If so, please describe
Have you ever been fired, laid off or quit a job? *
If so, please describe
With whom was your longest length of employment? *
How do you generally get along with bosses, colleagues etc.? *
Have you ever filed bankruptcy? *
If so, when?

Month Day Year
Date
Do you currently have financial stressors?
If so, please describe
FAMILY OF ORIGIN
Where were you born and raised? *
What was it like growing up? Describe your experience... *
Did you grow up religious/spiritual?
If so, please describe
If you currently practice, please describe your religious/spiritual practices
Who were you raised by? *
Are these individual(s) alive? *
If not alive, how and when did said individual(s) die?
If alive, please describe your current relationship with these individual(s)
Also, please provide details as to their age, residence, employment status/occupation
Of your parents/caretakers, who were you the closest? *
Do you have siblings? *
If so, please indicate oldest to youngest and where you are in the birth order
How would you describe your relationship with your siblings?
CURRENT RELATIONSHIPS
Please indicate your current relationship status
If applicable, please describe the relationship with your partner(s)
Do you have children? *
If so, please list their names/ages
If applicable, how do you get along with your children/step-children etc.?
SOCIAL HISTORY
Have you ever been arrested? *
If so, please describe
Please describe how you spend your free time *
How would others who know you well describe you? *
In childhood and/or adolescence, were you ever physically, emotionally or sexually abused? *
As an adult, have you ever been physically, emotionally or sexually abused *
Should be Empty:

INTAKE FORM

CURRENT ISSUE

SYMPTOM CHECKLIST

MEDICAL HISTORY

MEDICATIONS/OTC

ADDITIONAL MEDICAL INFO

ALCOHOL & DRUG USE

EDUCATION

EMPLOYMENT

FAMILY OF ORIGIN

CURRENT RELATIONSHIPS

SOCIAL HISTORY