Clinical Intake Form
Patient Name:_____________________________________
Page 1
CLINICAL INTAKE FORM
Date:__________________________________
Name:___________________________________________ SS#__________________________________
Address:________________________________________________________________________________
City:________________________________________ Zip Code:__________________________________
Home Phone #:_______________________________ Cell Phone#:_____________________________
Email Address:____________________________________________________________________________
*note: email correspondence is not considered a confidential form of communication.
DOB:_____________________ Age:______________________ Race:________________________________
Marital Status: ☐ Single ☐ Married ☐ Living Together ☐Separated
☐ Divored ☐ Widowed
Number of Children: _____________________ Ages:_______________________
Education/Employment:
Highest Grade Completed:____________________ Year:________________
Degree Received:______________________________________________________
Current Employer/School:_____________________________________________
Job Title:__________________________________________________________________
Number of years at this job:____________________________________________
Clinical Intake Form
Patient Name:_____________________________________
Page 2
General Health and Mental Health Information:
Presenting Problem(s):
Please describe your reason for coming in:
How would you describe your current physical heatlth? (please circle)
Poor
Unsatisfactory
Satisfactory
Good
Excellent
Please list any specific health problems (past and present):
Any history of surgery? Please list type of surgery and date(s):
Have you ever had a head injury?____________________ When?_____________________________
Loss of consciousness?____________________________ How long?______________________________
Please list all medications you are currently taking (prescription and over-thecounter):
_________________________________________________________________________________________________
Any recent changes in functioning/mood?
Difficulty sleeping? Please describe:
Difficulty eating? Please describe:
Clinical Intake Form
Patient Name:_____________________________________
Page 3
How would you describe your current mood? (please circle all that apply):
Cheerful
Sad
Depressed
Angry
Frustrated
Apathetic
Restless
Anxious
Calm
Irritable
Have you ever been psychiatrically hospitalized? Yes__________ No_____________
If so, when and where?______________________________________________________________________
What was the reason for your hospitalization?____________________________________________
Have you ever received therapy or counseling in the past? Yes________ No___________
If so, when and with whom?________________________________________________________________
Do you have any history of suicidal ideation? Yes_______ No________
If so, when?__________________________________________________________________________________
Do you have any history of homicidal ideation? Yes_______ No________
If so, when?__________________________________________________________________________________
Do you currently have thoughts of wanting to harm yourself? Yes_________ No________
Do you currently have thoughts of wanting to harm others? Yes_________ No________
Family Mental Health History:
(Please circle all that apply and identify the family member(s) that suffer from that
disorder).
___
Alcohol/Substance Abuse
Anxiety
Depression
Eating Disorder
Obessive Compulsive Disorder
Schizophrenia
Suicide Attempts
Please Circle
yes/no
yes/no
yes/no
yes/no
yes/no
yes/no
yes/no
List Family Member
Clinical Intake Form
Patient Name:_____________________________________
Page 4
Substance Use:
Do you drink alcohol? Yes_______ No__________ How many per day________ week_______
Do you currently use recreational drugs? Yes_________ No__________
What type?__________________
Have you any history of recreational drug use? Yes______ No_________
What type?_____________________
Have you ever sought alcohol/drug treatment? Yes________ No__________ When?_______
Do you smoke cigarettes? Yes________ No___________ Amount per day___________________
Daily Activities:
Who do live with? Family__________ Friend__________ Alone_________ Other__________
Which of the following tasks do you do independently? (please circle all that apply)
Dress
Bathe
Shopping
Household Chores
Cooking
Cleaning
Driving
Errands
What outside activites do you participate in?_____________________________________________
What are you hobbies?______________________________________________________________________
Do you pay/manage your own finances? Yes______ No_______
If not, who does?___________________________________________________________________________