Intake Form - Ivydale Wellness Center

Date Form Is Filled *

First Name *

Last Name *

Date of Birth *

Patient Phone Number *

Patient's Email Address *

Street Address *

Apartment, suite, etc

City

State/

ZIP / Postal Code

Emergency Contact

First Name *

Last Name

Street Address *

Apartment, suite, etc

City

State

ZIP / Postal Code

Email Address *

Phone *

Pharmacy Information

Pharmacy Name *

Pharmacy Phone Number *

Street Address *

Apartment, suite, etc

City

State

ZIP / Postal Code

Case Worker's First Name *

Case Worker's Last Name *

Caseworker’s Phone No *

Caseworker’s Email Address *

Consent for care information sharing

First NamePrimary Care Physician's First Name

Last NamePrimary Care Physician's Last Name

Do you give permission for ongoing regular updates to be provided to your primary Physician? *YesNo

Current Therapist/Counselor

Prefix

Therapist/Counselor's First Name

Therapist/Counselor's Last Name

Therapist's Phone Number

What are the problem(s) for which you are seeking help? *

Symptoms *Difficulty falling asleepDifficulty staying asleepDifficulty getting out of bedNot feeling rested in the morningPlease check any symptoms or experiences that you have had in the last month

Average hour of sleep per night *

Describe *

Behavior *Repetitive behaviors or mental acts (i.e. counting, checking doors, washing hands etc.)Outbursts of angernone

Are you trying to lose weight? *YesNo

Weight gain (lbs)

Weight loss (lbs)

Do you currently feel that you don't want to live? *YesNo

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? *YesNo

Is the method you would use readily available? *YesNo

Have you planned a time for this? *YesNo

Is there anything that would stop you from killing yourself? *YesNo

Do you feel hopeless and/or worthless? *YesNo

Have you ever tried to kill or harm yourself before? *YesNo

Do you have access to guns? *YesNo

Please Explain *

Allergies *

Current Weight *

Current 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: (Put None if there is none)

Past surgeries (If none, Put none)

Past Psychiatric Hospitalization *YesNo

When, how long and reason

Have you ever had an EKG? *YesNo

Date *

Was the EKG *Normal?Abnormal?Unknown?

For women only

Date of last menstrual period

Are you currently pregnant or do you think you might be pregnant? *YesNo

Are you planning to get pregnant in the near future? *YesNo

Birth control method

How many live births?

Do you have any concerns about your physical health that you would like to discuss with us?

Date and place of last physical exam:

Past Psychiatric History

Outpatient treatment *YesNo

Please describe when, by whom, and nature of treatment. *Reason Dates Treated By Whom

Psychiatric Hospitalization *YesNo

If yes, please describe when, by whom, and nature of treatment. *Reason Dates Treated By Whom

Your Exercise Level

Do you exercise regularly? *YesNo

How many days a week do you get exercise?

How much time each day do you exercise?

What kind of exercise do you do?

Family Psychiatric History

Substance Use

Have you ever been treated for alcohol or drug use or abuse? *YesNo

For which substances?

Where were you treated and when?

In the past three months, what is the largest amount of alcoholic drinks you have consumed in one day ?

Do you think you may have a problem with alcohol or drug use? *YesNo

Have you used any street drugs in the past 3 months? *YesNo

Which ones?

Have you ever abused prescription medication? *YesNo

Which ones and for how long?

Tobacco History

Have you ever smoked cigarettes?YesNo

Currently?

How many packs per day on average? *

How many years? *

In the past?

How many years did you smoke?

When did you quit?

Pipe, cigars, or chewing tobacco:

Currently? *YesNo

In the past? *YesNo

What kind?

How often per day on average?

How many years?

Family Background and Childhood History

Were you adopted?YesNo

Where were you born?

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?YesNo

How old were you when they divorced?

If your parents divorced, who did you live with?

Describe your father and your relationship with him

Describe your mother and your relationship with her

Trauma History

Do you have a history of being abused emotionally, sexually, physically or by neglect?YesNo

Please describe when, where and by whom:

Educational History

Highest Grade Completed?

What is your highest educational level or degree attained?

Occupational History

Employment History (Most recent first)

Relationship History and Current Family

Are you sexually active?YesNo

Describe your relationship with your spouse or significant other

Do you have children?YesNo

Please list their names and ages

Name

Sex

Age

Who currently lives in your residence?Please list their names, relationship and ages

Name

Relation

Sex

Age

Legal History

Have you ever been arrested?YesNo

Do you have any pending legal problems?YesNo

Spiritual Life

Do you belong to a particular religion or spiritual group?YesNo

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 helpfulStressful

Is there anything else that you would like us to know?

Patient Signature *

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Date of Submission *

Mental Health Intake Form

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