ADULT INTAKE INFORMATION
IDENTIFYING INFORMATION:
Today’s date: ___________________________
Therapist:
____________________
Client Name: __________________________________________
Address:__________________________________________________________________________________
Street Address
City
State
Zip
Phone Number at (home) _______________ at (work)____________
Can we call you at home? _____
at work? _____
Emergency contact (phone number, relationship) _________________________________________________
Marital Status: ______________ If married, number of years____________
Dates of previous marriages, if any ______________________________________________________
Education: ( Highest year of schooling completed; diploma or degree, if applicable; or current year and name of
school.)_____________________________________________________________________
What kind of work do you do? _________________________________________________________
If employed, present employer: ____________________________________ How long? __________
What is your primary reason for coming to Arubah Emotional Health Services at this time?
__________________________________________________________________________________________
________________________________________________________________________________________
Area
Family / Children
Marital Relationship
Other Relationships
Employment
Finances
Living situation
School
Legal Problems
Other (specify)
Please check the areas that are problems or concerns for you:
Comments
SYMPTOM / PROBLEMS LIST
Circle any item that has been a concern or problem and indicate how long.
Physical
Sleep problems
Fatigue / loss of energy
Appetite change / weight loss or gain
Headaches
Nausea, diarrhea, or other abdominal distress
Dizziness or faintness
PCC118 (10/96)
Physical continued
Shortness of breath
Comments
How Long?
Comments
(see reverse side)
How Long?
Trembling or shaking
Trouble swallowing / “lump in throat”
Palpitations / accelerated heart rate
Nightmares / frightening dreams
Sweating
Premenstrual Syndrome (PMS)
Mood
Depressed mood
Loneliness
Frequent crying
Mood swings
Feeling of helplessness and hopelessness
Lack of interest in most activities
Low self-esteem
Thoughts about suicide
Suicide plans
Suicide attempts
Irritability
Anxiety
Excessive worry
Anxiety, nervousness
Panic attacks
Fears (including phobias)
Social fears, shyness
Guilty feelings
Behavior
Withdrawal, isolation
Lack of assertiveness
Perfectionism
Hyperactivity
Irritability
Aggressive behavior
Self-harming behavior
Thoughts, Perceptions
Problems with memory
Difficulty concentrating
Disorientation / confusion
Excessive fantasy / daydreaming
Preoccupation
Racing thoughts
Hallucinations (voice / visions)
Other ___________________________________________________________________________
ALCOHOL AND DRUG USE
Have you or others ever thought your use of alcohol or drugs was a problem?
Alcohol
Smoking
Other Drugs
____ Yes
____ Yes
____ Yes
____No
____No
____No
Date of last alcohol or drug use: ____________________ Last intoxication: ___________________
Amount / type use per week: _________________________________________________________
Caffeine use in cups / bottles per day: Coffee ___________ Tea___________ Soft Drinks: _______________
Tobacco use per day: Cigarettes _____ Cigars ____ Pipe _____ Other _____
Do you have a history of chemical dependency treatment? ________
If yes, when / where? _______________________________________________________________________
Do you attend AA or other similar groups? ______________________________________________________
Have any blood relatives that have problems with substance abuse or use?
__________________________________________________________________________________________
__________________________________________________________________________________________
MENTAL HEALTH HISTORY
Please list type of previous therapy, treatment, hospitalizations and/or evaluations:
When
Where
By Whom
__________________________________________________________________________________________
__________________________________________________________________________________________
_______________________________________________________________________________________
Have any blood relatives experienced significant mental or emotional problems? If so, please specify.
__________________________________________________________________________________________
________________________________________________________________________________________
ABUSE HISTORY
Have you ever been abused?
Physically
Yes___
No___
Not Sure___
Emotionally
Yes___
No___
Not Sure___
Sexually
Yes___
No___
Not Sure___
Comments:________________________________________________________________________________
________________________________________________________________________________________
Was abuse a problem in your family when you were growing up?
_________________________________________________________________________________________
Is it presently a problem?____________________________________________________________________
(see reverse side)
MEDICAL
Primary physician:__________________________________ Date of last physical exam:_________________
Significant operations and illnesses (including chronic illnesses and significant childhood illnesses):
__________________________________________________________________________________________
________________________________________________________________________________________
List all prescribed medicines using now, with dosages if possible:
__________________________________________________________________________________________
________________________________________________________________________________________
List any medicines previously used for emotional problems: Were they helpful?
__________________________________________________________________________________________
________________________________________________________________________________________
Over-the-counter medicines used frequently: ____________________________________________________
Allergies to drugs or medicines: ______________________________________________________________
Do you have any family history of medical concerns? _____________________________________________
CONCLUDING QUESTIONS
Is religion and/or spirituality important in your life? _______________________________________________
_________________________________________________________________________________________
Are there people in your life who are helpful to you? If so, please describe.
__________________________________________________________________________________________
________________________________________________________________________________________
What do you consider your major strengths?
__________________________________________________________________________________________
________________________________________________________________________________________
Is there anything else you feel it would be helpful for us to know?
Thank you for your time.