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609 583 4969
[email protected]
1901 North Olden Avenue Ext, Suite 11A, Ewing, NJ 08618
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609 583 4969
[email protected]
1901 North Olden Avenue Ext, Suite 11A, Ewing, NJ 08618
Facebook
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Instagram
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Intake Form
Fill and submit the form below with the correct information.
NAME
(Required)
Enter Name Here
DATE OF BIRTH
AGE
Marital Status
Single
Married
Separated
Divorced
Widowed
Same Sex Partnership
Other
Gender
Male
Female
ADDRESS
PHONE NUMBER
SOCIAL SECURITY NUMBER
EMERGENCY CONTACT
PHONE NUMBER
DOES ANYONE ELSE LIVE IN THE SAME HOME WITH YOU?
Yes
No
NAME
AGE
RELATIONSHIP
NAME
AGE
RELATIONSHIP
NAME
AGE
RELATIONSHIP
IN YOUR OWN WORDS, PLEASE TELL US A LITTLE ABOUT WHAT HAS BEEN GOING ON THAT YOU NEED HELP WITH. I'LL COVER THE DETAILS DURING OUR FACE TO FACE VISIT SO DON'T WORRY ABOUT PUTTING EVERYTHING DOWN OR FORGETTING SOMETHING. HOW LONG HAS IT BEEN GOING ON? DID SOMETHING CAUSE IT OR MAKE IT WORSE? HOW SEVERE IS IT? DOES ANYTHING HELP YOU FEEL BETTER? IF SO, WHAT? DO YOUR SYMPTOMS COME AND GO OR ARE THEY CONSTANT? PUT DOWN ANY OTHER INFORMATION THAT YOU THINK WILL HELP ME GET TO KNOW YOU BETTER.
PAST PSYCHIATRIC HISTORY
PLEASE LIST ANY OTHER PERSON WHO HAS BEEN PROVIDING OR HAS PROVIDED MENTAL HEALTH CARE FOR YOU AND WHEN YOU WERE UNDER THEIR CARE. THIS MAY BE ANOTHER PSYCHIATRIST, A PSYCHOLOGIST, SOCIAL WORKER, SCHOOL COUNSELOR, INDIVIDUAL THERAPIST, MARITAL THERAPIST, MINISTER, PRIEST OR PASTORAL COUNSELOR. YOU SHOULD INCLUDE ANYONE WHO HAS PRESCRIBED PSYCHIATRIC MEDICATION FOR YOU (PRIMARY CARE PROVIDER, OBGYN, FAMILY NURSE PRACTITIONER, OTHER HEALTH CARE PROVIDER.
PROVIDER
WHEN SEEN
MM slash DD slash YYYY
PROVIDER
WHEN SEEN
MM slash DD slash YYYY
PROVIDER
WHEN SEEN
MM slash DD slash YYYY
LIST ALL CURRENT MEDICATIONS, DOSAGE, INSTRUCTIONS, WHO PRESCRIBES THEM AND WHAT YOU TAKE THEM FOR:
MEDICATION/DOSE
INSTRUCTIONS
CONDITION TREATED
PRESCRIBE
MEDICATION/DOSE
INSTRUCTIONS
CONDITION TREATED
PRESCRIBE
MEDICATION/DOSE
INSTRUCTIONS
CONDITION TREATED
PRESCRIBE
HAVE YOU EVER ATTEMPTED SUICIDE?
Yes
No
PLEASE DESCRIBE BELOW
HAVE YOU EVER BEEN PSYCHIATRICLY HOSPITALIZED?
Yes
No
WHERE?
WHEN
MM slash DD slash YYYY
IF YOU HAVE BEEN ON OTHER PSYCHIATRIC MEDICATION IN THE PAST PLEASE LIST THEM HERE
ALCOHOL AND DRUG HISTORY
ALCOHOL USE
None
Rarely
Sometimes
Often
IF YOU DRINK AT ALL, WHAT ALCOHOL CONTAINING BEVERAGE/S DO YOU USUALLY DRINK?
HOW LONG AGO WAS THE LAST TIME YOU HAD A DRINK?
Untitled
I have tried to cut back on my drinking.
I have become angered or annoyed by others criticizing my drinking.
I feel guilty about my drinking.
I have gotten up in the morning and had a drink to steady my nerves.
Alcohol
AGE AT FIRST USE
HOW MUCH USED HOW OFTEN
LAST USED
MARIJUANA
AGE AT FIRST USE
HOW MUCH USED HOW OFTEN
LAST USED
COCAINE
AGE AT FIRST USE
HOW MUCH USED HOW OFTEN
LAST USED
CRYSTAL METH
AGE AT FIRST USE
HOW MUCH USED HOW OFTEN
LAST USED
ICE
AGE AT FIRST USE
HOW MUCH USED HOW OFTEN
LAST USED
ADDERALL
AGE AT FIRST USE
HOW MUCH USED HOW OFTEN
LAST USED
VYVANSE
AGE AT FIRST USE
HOW MUCH USED HOW OFTEN
LAST USED
RITALIN
AGE AT FIRST USE
HOW MUCH USED HOW OFTEN
LAST USED
LSD
AGE AT FIRST USE
HOW MUCH USED HOW OFTEN
LAST USED
XTC/MOLLY
AGE AT FIRST USE
HOW MUCH USED HOW OFTEN
LAST USED
PEYOTE
AGE AT FIRST USE
HOW MUCH USED HOW OFTEN
LAST USED
KETAMINE
AGE AT FIRST USE
HOW MUCH USED HOW OFTEN
LAST USED
MUSHROOMS
AGE AT FIRST USE
HOW MUCH USED HOW OFTEN
LAST USED
XANAX
AGE AT FIRST USE
HOW MUCH USED HOW OFTEN
LAST USED
VALIUM
AGE AT FIRST USE
HOW MUCH USED HOW OFTEN
LAST USED
KLONOPIN
AGE AT FIRST USE
HOW MUCH USED HOW OFTEN
LAST USED
ATIVAN
AGE AT FIRST USE
HOW MUCH USED HOW OFTEN
LAST USED
DEXTROMETHORPHAN
AGE AT FIRST USE
HOW MUCH USED HOW OFTEN
LAST USED
STEROIDS
AGE AT FIRST USE
HOW MUCH USED HOW OFTEN
LAST USED
SPICE
AGE AT FIRST USE
HOW MUCH USED HOW OFTEN
LAST USED
BATH SALTS
AGE AT FIRST USE
HOW MUCH USED HOW OFTEN
LAST USED
ON AVERAGE HOW MUCH DO YOU SPEND PER WEEK ON ALCOHOL AND/OR DRUGS?
PLEASE LIST PLACES WHERE YOU HAVE BEEN TREATED FOR ALCOHOL OR DRUG-RELATED PROBLEMS BELOW:
FACILITY
WHEN
MM slash DD slash YYYY
FOR WHAT
TREATMENT
Finished treatment
Left early
FACILITY
WHEN
MM slash DD slash YYYY
FOR WHAT
TREATMENT
Finished treatment
Left early
FACILITY
WHEN
MM slash DD slash YYYY
FOR WHAT
TREATMENT
Finished treatment
Left early
HAVE YOU EVER PARTICIPATED IN 12-STEP RECOVERY (AA/NA)?
Yes
No
DO YOU CURRENTLY PARTICIPATE IN 12-STEP RECOVERY?
Yes
No
PAST MEDICAL HISTORY
LIST MEDICAL PROBLEMS BELOW
PAST SURGICAL HISTORY
LIST ALL SURGERIES BELOW
ALLERGIES
FAMILY HISTORY
PLEASE LIST RELATIVES WITH MENTAL ILLNESS, CHEMICAL DEPENDENCY OR COMPLETED SUICIDE HERE
PLEASE LIST RELATIVES WITH OTHER ILLNESSES HERE
PSYCHOSOCIAL HISTORY
WHERE WERE YOU BORN?
WHERE DID YOU GROW UP?
WHO RAISED YOU?
HOW MANY BROTHERS AND SISTERS DID YOU HAVE?
WHAT WAS YOUR CHILDHOOD LIKE?
DID ANYONE EVER PHYSICALLY ABUSE YOU?
Yes
No
WHO?
DID ANYONE EVER EMOTIONALLY ABUSE YOU?
Yes
No
WHO?
DID ANYONE EVER SEXUALLY ABUSE YOU?
Yes
No
WHO?
WHAT IS YOUR HIGHEST LEVEL OF EDUCATION?
Yes
No
WHO?
ARE YOU EMPLOYED?
Yes
No
WHAT DO YOU DO?
DID YOU EVER WORK?
Yes
No
WHAT JOBS DID YOU HAVE IN THE PAST?
ARE YOU MEDICALLY DISABLED?
Yes
No
FOR WHAT REASON?
HOW MANY TIMES HAVE YOU BEEN MARRIED?
LIST ALL MARRIAGES, HOW LONG THEY LASTED AND IF THEY ENDED WHAT THE REASON WAS
HOW MANY CHILDREN DO YOU HAVE? PLEASE LIST ALL CHILDREN AND FROM WHAT RELATIONSHIP THEY ARE FROM
WHAT IS YOUR SEXUAL PREFERENCE?
Heterosexual
Bisexual
Homosexual
PLEASE BRIEFLY EXPLAIN
ARE YOU CURRENTLY ON PROBATION?
ARE YOU CURRENTLY INVOLVED IN A LAWSUIT?
Yes
No
PLEASE BRIEFLY EXPLAIN
WHAT RELIGION ARE YOU?
ARE THERE ANY OTHER THINGS THAT WOULD BE HELPFUL TO KNOW ABOUT YOU THAT WERE NOT COVERED ALREADY?
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