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iMind Mental Health and Wellness (731) 300-0810 168 W. University Parkway Suite C Jackson TN 30805
PATIENT INTAKE FORM
The therapy and counseling work we do is unique to you, just as it is to each one of our clients.
Before your first visit, we need to collect some general information from you.
GENERAL INFORMATION
FIRST NAME LAST NAME
GENDER DATE OF BIRTH SSN
ADRESS
CITY STATE ZIP
MAIN PHONE OTHER PHONE
SUPPORTIVE LIVING ENTITY
PROGRAM MANAGER
PHONE EMAIL
EMERGENCY CONTACT
FIRST NAME LAST NAME
PHONE RELATIONSHIP
INSURANCE INFORMATION
PRIMARY INSURANCE POLICY HOLDER
POLICY HOLDER DOB RELATIONSHIP
POLICY HOLDER ADDRESS
CITY STATE ZIP
POLICY NUMBER GROUP NUMBER
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iMind Mental Health and Wellness (731) 300-0810 168 W. University Parkway Suite C Jackson TN 30805
SECONDARY INSURANCE INFORMATION
SECONDARY INSURANCE POLICY HOLDER
POLICY HOLDER DOB RELATIONSHIP
POLICY HOLDER ADDRESS
CITY STATE ZIP
POLICY NUMBER GROUP NUMBER
FINANCIALLY RESPONSIBLE PARTY
FIRST NAME LAST NAME
ADRESS
CITY STATE ZIP
MAIN PHONE OTHER PHONE/EMAIL
RELATIONSHIP TO PATIENT
PRIMARY CARE PROVIDER
NAME PHONE NUMBER
PHARMACY
NAME PHONE NUMBER
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Please, complete all information on this form and bring it to the first visit. It may seem long, but most
of the questions require only a check, so it will go quickly. You may need to ask family members about
the family history. Thank you.
Name: _________________________________ Date of Birth: __________ Gender: _____________
Primary Care Physician (PCP): ________________________________ PCP Phone: ________________
Are you receiving mental health treatment at this time? Yes No If YES, where: ________________
_____________________________________________________________________________________
What mental health services are you seeking from Support Solutions? (Check all that apply.)
Psychiatry Therapy/counseling Intensive Outpatient Treatment
Why are you seeking mental health treatment at this time?
1. ______________________________________________________________________________
2. ______________________________________________________________________________
3. ______________________________________________________________________________
What do you hope to gain from mental health treatment? What would you like to be different?
1. ______________________________________________________________________________
2. ______________________________________________________________________________
3. ______________________________________________________________________________
What do you like about yourself? What are your personal strengths? _____________________________
_____________________________________________________________________________________
What are your interests and hobbies? ______________________________________________________
_____________________________________________________________________________________
What is important to you? _______________________________________________________________
_____________________________________________________________________________________
What helps you to feel calm? _____________________________________________________________
Current Symptoms Checklist: (check for any symptoms present, twice for major symptoms)
Depressed Mood
Unable to enjoy activities
Increased need for sleep
Decreased need for sleep
Loss of interest
Decrease in energy
Concentration/
forgetfulness
Change in appetite
iMind Mental Health and Wellness Intake Form
?
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Excessive guilt
Fatigue
Decreased libido
Increased libido
Racing thoughts
Impulsivity
Risky behavior (explain,
________________________
_______________________)
Excessive energy
Increased irritability
Crying spells
Excessive worry
Anxiety attacks
Avoidance
Hallucinations
Suspiciousness
Suicidal thoughts
Self-harm (explain,
________________________
_______________________)
Other, _______________
Other, _______________
Violent thoughts
Violence toward others
(anyone specific?)
_______________________
_______________________
Suicide Risk Assessment
Hae you eer had feeligs or thoughts that you did’t at to lie? Yes No
If YES, please, answer the following. If NO, please, skip to the next section.
Do you urretly feel that you do’t at to lie? Yes No
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? ____________________________________
Would anything make it better? __________________________________________________________
Do you have a plan to kill yourself? ________________________________________________________
Is the method you would use readily available? ______________________________________________
Is there anything that would stop you from killing yourself? ____________________________________
Do you feel hopeless and/or worthless? ____________________________________________________
Have you ever tried to kill yourself before? __________________________________________________
Do you have access to guns, weapons, medications, or anything you can hurt yourself with?
Please Check All Symptoms That Apply
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Yes No If YES, please, explain. ______________________________________________________
Medical Information
Allergies: _____________________________ Current Weight: __________ Current Height: ______
List ALL current prescription medications and how often you take them. A copy of your MAR is fine.
Medication Name
Reason
Total Daily Dosage
Estimated Start Date
Current over-the-counter medications or supplements
Medication/ Supplement Name
Reason
For women only: Are you currently pregnant or do you think you may be pregnant? Yes No
Do you have any concerns about your physical health that you would like to discuss with us? Yes No
Date and place of last physical exam: ______________________________________________________
Personal and Family Medical History/Status
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You
Family Member(s)
Which Family Member(s)?
Anemia
Asthma/respiratory problems
Cancer (type)
Chronic Fatigue
Chronic Pain
Diabetes
Epilepsy or seizures
Fibromyalgia
Head trauma/ Traumatic Brain
Injury
Heart Disease
High blood pressure
High cholesterol
Intellectual or Developmental
Disability
Kidney Disease
Liver Disease/ problems
Stomach or intestinal problems
Thyroid Disease
Other
Past medical problems, non-psychiatric hospitalizations or surgeries: _____________________________
_____________________________________________________________________________________
Have you ever had an EKG? Yes No Was the EKG normal abnormal unknown
Mental Health History/Status
Have you participated in outpatient mental health treatment before? Yes No If YES, describe.
Reason for outpatient
mental health treatment
Dates
Treated
By Whom (Where)
Was it a positive OR
negative experience?
Have you been hospitalized for mental health treatment before? Yes No If YES, describe.
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Reason for inpatient
mental health treatment
Dates Treated
By Whom (Where)
Was it a positive or
negative experience?
Past psychotropic medications: If you have ever taken any of the following medications, please, indicate
the dates ad ho helpful the ediatio as. (If you a’t reeer all the details just rite i hat
you do remember.)
Dates
Response/ Side-Effects
Antidepressants
Anafranil
(clomipramine)
Celexa (citalopram)
Cymbalta (duloxetine)
Effexor (venlafaxine)
Elavil (amitriptyline)
Lexapro (escitalopram)
Luvox (fluvoxamine)
Pamelor (nortrptyline)
Paxil (paroxetine)
Prozac (fluoxetine)
Remeron (mirtazapine)
Serzone (nefazodone)
Tofranil (imipramine)
Wellbutrin (bupropion)
Zoloft (sertraline)
Other
Mood Stabilizers
Depakote (valproate)
Lamictal (lamotrigine)
Lithium
Tegretol
(carbamazepine)
Topamax (topiramate)
Other
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Dates
Response/ Side-Effects
Antipsychotics/Mood
Stabilizers
Abilify (aripiprazole)
Clozaril (clozapine)
Geodon (ziprasidone)
Haldol (haloperidol)
Prolixin (fluphenazine)
Risperdal (risperidone)
Seroquel (quetiapine)
Zyprexa (olanzepine)
Other
Sedative/Hypnotics
Ambien (zolpidem)
Desyrel (trazaodone)
Restoril (temazepam)
Rozerem (ramelteon)
Sonata (zaleplon)
Other
ADHD medications
Adderall
(amphetamine)
Concerta
(methylphenidate)
Ritalin
(methylphenidate)
Strattera (atomoxetine)
Other
Antianxiety
medications
Ativan (lorazepam)
Buspar (buspirone)
Klonopin (clonazepam)
Tranxene (clorazepate)
Xanax (alprazolam)
Valium (diazepam)
Other
Substance Use
Have you had treatment for alcohol or drug abuse? Yes No Which substances? _______________
_____________________________________________________________________________________
In the past 3 months, what is the largest amount of alcohol you have consumed in one day? __________
Have you used street drugs in the past 3 months? Yes No Which drugs? ______________________
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Have you ever abused prescription medication? Yes No
If YES, which one(s) and for how long? _____________________________________________________
Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a
hangover? Yes No
Has anyone said that you may have a problem with alcohol or drug use? Yes No
Do you think you may have a problem with alcohol or drug use? Yes No
Have ever tried the following?
Yes
No
If YES, how long and when did you last use?
Alcohol
Cocaine
Ecstasy
Heroin
LSD or hallucinogens
Marijuana
Methadone
Methamphetamine
Pain killers (not as prescribed)
Stimulant (pills)
Tranquilizer/ sleeping pills
Other?
Tobacco and Caffeine
How many caffeinated beverages do you drink a day?
Coffee __________ Sodas ___________ Tea ___________ Energy Drinks _____________
Do you currently smoke? Yes No If YES, for how many years? ________________
Pipe, cigars, or chewing tobacco: Currently use? Yes No
What kind? _________________________________ For how many years? _____________
Family Background and Childhood History
Ethnic/ cultural background: _____________________________________________________________
Were you adopted? Yes No Where did you grow up? ________________________________
Who did you live with when you were a child? ______________________________________________
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What was your relationship like with the person or people who raised you? _______________________
_____________________________________________________________________________________
How old were you when you left home? _____
Trauma History or Trauma Witnessed
Have you experienced?
Physical Abuse: Yes No
Emotional abuse: Yes No
Neglect: Yes No
Sexual Abuse as Victim: Yes No
Sexual Abuse as Perpetrator: Yes No
Have you witnessed anyone being abused? Yes No
Has anyone in your immediate family died? _________________________________________________
Have you experienced any distressful or painful events that still bother you? Yes No
Please, elaborate on any YES responses. ___________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Educational History
Highest grade completed? __________ Where? ______________________________________________
Did you participate in Special Education? Yes No Describe. _______________________________
Completed some college or vocational training? Yes No Describe. _________________________
Completed four year degree? Yes No Describe. ______________________________________
Completed graduate degree? Yes No Describe. ______________________________________
Reading Level:
Cannot read
Can read some
Can read very well
Writing Level:
Cannot write
Can write some
Can write very well
Do you need assistive technology? Yes No Describe. ____________________________________
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Do you need an interpreter (sign language or language other than English)? Yes No Describe.
_____________________________________________________________________________________
Occupational History
Are you currently: Working Unemployed, looking for work Unemployed, not looking for work
Disabled Retired Student
Where do you work? ____________________________________ For how long? ___________________
What kind of work have you done in the past? _______________________________________________
Have you ever served in the military? Yes No Describe. _______________________________
Relationships and Current Living Situation
Are you currently: Single Married Divorced Widowed Partnered
How long have you been married or partnered? ________
How long have you been divorced or widowed? _________
If you are not married or partnered, are you currently in a relationship? Yes No
Describe your relationship with your spouse/ significant other. __________________________________
How would you identify your sexual orientation?
straight/heterosexual lesbian/ gay/ homosexual bisexual transgender
unsure/ questioning asexual other, ___________ prefer not to answer
Do you have children? Yes No How many? ______________
Where do you live? alone, without paid supports alone, with paid supports
supported housing/living with family/ significant other/ natural supports Other, ___________
Who lives with you?
Name
Relationship
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Legal
Have you ever been arrested? Yes No Describe. ________________________________________
Do you have any pending legal problems? Yes No Describe. _______________________________
Spiritual/Religious
What is your religious preference? __________________
Do you find your involvement helpful during this time in your life? Yes No
How does practicing your religion help you?
Describe. _____________________________________________________________________________
Is there anything else you would like us to know?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Who helped you to complete this form? ____________________________________________________
Signature of Person to be Served: _______________________________________ Date: ________
Do not write below this line.
For Clinic Use Only: Admission Date (the date of the FIRST appointment): ______________
Intake form has been reviewed Cliicia’s iitials: ____________
Initial assessment session or initial psychiatric evaluation has been completed with the person to be
served. (*See session note or psych. eval.) Cliicia’s iitials: ____________
Based on review of this information and the initial assessment session or initial psychiatric evaluation
with the person to be served, this person CAN be supported appropriately y the Support Solutios’
Outpatient Mental Health Clinic. Cliicia’s iitials: ____________
OR
Based on review of this information and the initial assessment session or initial psychiatric evaluation
with the person to be served, this person CANNOT e supported appropriately y the Support Solutios’
Outpatient Mental Health Clinic AND a referral has been made to _______________________________.
Cliicia’s iitials: ____________
Cliiia’s Prited Nae ad Title: _________________________________________________________
Cliiia’s Sigature: ______________________________________ Date: _____________________
Reviewed by: __________________________________________ Date: _____________________
by iMind Mental Health and Wellness.
by iMind Mental Health and Wellness.
Signature of Patient or Guardian
