Intake Form - New Patients PATIENT INFORMATION * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Birth Date * MM DD YYYY Phone * (###) ### #### Email * Gender assigned at birth Male Female ALLERGIES Are you allergic to any medication or food? * REASON FOR YOUR VISIT TODAY Why are you seeking help now? Describes your symptoms and concerns. * PAST & CURRENT MEDICAL DIAGNOSES Do you have any current or prior medical issues? Are you CURRENTLY under treatment for any medical condition? PAST PSYCHIATRIC DIAGNOSES: Do you have any past mental health issues? Have you been on PSYCHIATRIC medication in the past? If YES, please list MEDICATIONS Are you currently prescribed any medications? Specify all medications and supplements you are presently taking and for what reason. (Medication - Dosage - How long have you been taking it? - Has it been helpful? - Side effects). PSYCHIATRIC/MEDICAL HOSPITALIZATIONS & RELATED DIAGNOSIS Have you seen a counselor, psychologist, psychiatrist or other mental health professional before? Have you been hospitalized for psychiatric reasons? Have you ever attempted suicide? If YES, describe: OUTPATIENT PSYCHIATRIC TREATMENT/DIAGNOSIS HISTORY Have you been hospitalized in any treatment center? FAMILY HISTORY Has anyone in your family ever sought help for or experienced mental health (depression, anxiety, bipolar disorder, schizophrenia, suicide attempt) or substance use issues? if YES, please specified your relation. * SOCIAL HISTORY What is your relationship status (single, married, partner, divorced, widowed). Any children? Who lives with you currently? What is your current occupation? What do you do? How long have you been doing it? Have you ever been neglected, sexually, emotionally, or physically abused? Please describe. Do you now, or have you ever, used alcohol, tobacco, recreational drugs, or prescription medication other than as prescribed? How much? name of the drugs. What spiritual practices and cultural influences are important to you? What social activities and relationships do you engage in? Do you have any current or prior legal issues? or Have you been arrested? Yes No What was life as you were growing up, both at home and in school? What significant education and work/volunteer experiences have you had? What strengths and abilities are you bringing to sessions? What needs or preferences do you have that will help us be successful? What else would you like me to know? Please list an emergency contact (name, relationship, and phone number) Thank you for submitting your “Intake Form.” Advanced Medical Psychiatry Group is grateful to have you as a patient.
