"Psychiatric Intake Form - Pllc"

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Gilbert Counseling, PLLC
3721 Benson Drive
Raleigh, NC 27609
919.659.5ZEN (936)
Intake Form
Individual Information:
Name: _____________________________________________________________________________
(Last)
(First)
(Middle Initial)
Date of Birth: _____/_____/_____
Age:_______
Gender: (circle)
Male
Female
SSN: ______--______--______
Phone: Home____________________ Work____________________ Cell_____________________
May we leave a message at: (circle)
Home
Work
Cell
Email:____________________________________ May we email you? (circle) Yes
No
**Email correspondence is not considered to be a confidential mode of communication.
Current Marital Status: (circle)
Single
Engaged
Partnership
Married
Separated
Divorced
Widowed
Previous Marriage(s): State length of previous marriages and if they ended by divorce, separation or
death and when:
Reason(s) for Seeking Counseling:
Please describe your reason(s) for seeking counseling:_______________________________________
How long have you been aware of these concerns?__________________________________________
Do you have some idea of how these concerns developed?____________________________________
Is anybody else aware of your concerns? Is so, who?_________________________________________
Gilbert Counseling, PLLC
3721 Benson Drive
Raleigh, NC 27609
919.659.5ZEN (936)
Intake Form
Individual Information:
Name: _____________________________________________________________________________
(Last)
(First)
(Middle Initial)
Date of Birth: _____/_____/_____
Age:_______
Gender: (circle)
Male
Female
SSN: ______--______--______
Phone: Home____________________ Work____________________ Cell_____________________
May we leave a message at: (circle)
Home
Work
Cell
Email:____________________________________ May we email you? (circle) Yes
No
**Email correspondence is not considered to be a confidential mode of communication.
Current Marital Status: (circle)
Single
Engaged
Partnership
Married
Separated
Divorced
Widowed
Previous Marriage(s): State length of previous marriages and if they ended by divorce, separation or
death and when:
Reason(s) for Seeking Counseling:
Please describe your reason(s) for seeking counseling:_______________________________________
How long have you been aware of these concerns?__________________________________________
Do you have some idea of how these concerns developed?____________________________________
Is anybody else aware of your concerns? Is so, who?_________________________________________
How do you think or feel counseling may be able to help?____________________________________
What strengths do you bring with you to counseling?________________________________________
What about weaknesses?_______________________________________________________________
Previous Counseling or Psychiatric Treatment:
Have you ever received mental health services (counseling, psychotherapy, psychiatric care)? Y
N
(circle)
If yes, please list previous providers, dates, and length of treatment:
Are you currently taking any psychiatric medication? If so, please list below:
(
)
If you need additional space, please write on the back of this form
Medication
Dose
Frequency
Take as prescribed (Y/N)
Have you ever taken psychiatric medication in the past? If yes, please list and provide dates:
Have you ever been hospitalized? If yes, please indicate when, low long you were hospitalized, and the
reason:_____________________________________________________________________________
Health and Wellness:
How would you rate your current physical health? (circle)
Poor
Fair
Good
Very Good
Please describe any health concerns you are currently experiencing:____________________________
___________________________________________________________________________________
How would you describe your current sleep/rest? (circle)
Poor
Fair
Good
Very Good
Please describe any sleep concerns you are currently having:_________________________________
How would you describe your current eating habits/appetite? (circle)
Poor
Fair
Good
Very Good
Please describe any eating/appetite concerns you are currently experiencing: _____________________
How often do you exercise? ____________________________________________________________
What kind of exercise do you participate in? _______________________________________________
Are you currently experiencing any of the following: (circle)
Sadness
Anxiety
Panic
Depression
Grief
If yes, how long have you been experiencing these feelings? __________________________________
Are you currently experiencing any chronic pain? If yes, please describe: ________________________
How often do you drink alcohol? (circle) Never
Daily
Weekly
Monthly
Other:______________________
How often do you participate in recreational drug use? (circle)
Never
Daily
Weekly
Monthly
Other:______________________
How would you describe your social life? _________________________________________________
If you are in a romantic relationship, how would you describe the relationship currently?
Family Mental Health History:
Identify if there is a family history of any of the following. If yes, indicate the family member's
relationship to you.
Circle
Family Member
Alcoholism/Drug Addiction
Yes/ No
Anxiety/Phobias
Yes/ No
Major Depression/Bipolar (circle)
Yes/ No
Domestic Violence
Yes/ No
Eating Disorders
Yes/ No
Schizophrenia
Yes/ No
Suicide Attempts
Yes/ No
Family of Origin Information:
Parents:
Are both parents still living? Mother___________
Father____________ If not, how and when
did death occur? Mother_____________________
Father_____________________
Was your parents' marriage: (circle) happy
average
unhappy
very unhappy
Was either of your parents previously married?
Mother___________
Father____________
If yes, cause of end of previous marriage (death of spouse or divorce?)
Mother___________________
Father__________________
Was your home disrupted by:
Separation_________
Divorce___________ Death____________
Other_____________ If yes, how old were you? _______Who did you then live with?__________
Mother's Occupation:________________
Father's Occupation:_________________
Siblings:
Please list Name(s), Age(s), Gender, Step/Adopted, Marital Status, # of children, Occupation
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Family of Procreation:
Spouse, Partner, or Significant Other (first name):_________________________
Do you have children together? If yes, please list first name(s), age(s),
gender:_____________________________________________________________________________
Do (either of) you have children from previous relationships? If yes, please list first name(s), age(s),
gender, and where they live:____________________________________________________________
Any others who live with you? _________________________________________________________
Are any children deceased? If yes, how and when did this occur? ______________________________
Additional Information:
Are you currently employed? (circle) Yes
No
If yes, what kind of work?_____________________ Do you enjoy your work?___________________
Do you find your work to be causing stress right now?_______________________________________
What is your educational background? ___________________________________________________
Do you consider yourself to be spiritual or religious? (circle) Yes
No
Unsure
If yes, please describe: ________________________________________________________________
Thank you for taking the time to complete this intake form. If there is anything else you think I
should know, please describe below:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
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