Support Solutio s’ Outpatie t Me tal Health Cli ic I take/Assess e t For

iMind Mental Health and Wellness Intake Form

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: __________

Cristina Querubino 03171972
Gender: _____________
Female

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  Decreased need for sleep  Concentration/

forgetfulness
 Unable to enjoy activities  Loss of interest
 Change in appetite
 Increased need for sleep  Decrease in energy

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 Please
Support Check
Solutio All Symptoms
s’ Outpatie ThatCliApply
t Me tal Health ic I take/Assess e t For

 Excessive guilt  Anxiety attacks  Violent thoughts

 Fatigue  Avoidance  Violence toward others

 Decreased libido  Hallucinations (anyone specific?)

 Increased libido  Suspiciousness _______________________

 Racing thoughts  Suicidal thoughts _______________________

 Impulsivity  Self-harm (explain,

________________________
 Risky behavior (explain, _______________________)
________________________
_______________________)

 Excessive energy  Other, _______________

 Increased irritability  Other, _______________

 Crying spells

 Excessive worry

Suicide Risk Assessment

Ha e you e er had feeli gs or thoughts that you did ’t a t to li e?  Yes  No

If YES, please, answer the following. If NO, please, skip to the next section.

Do you urre tly feel that you do ’t a t to li e?  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?

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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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 Support Solutio s’ Outpatie t Me tal Health Cli ic I take/Assess e t For

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 Dates By Whom (Where) Was it a positive OR

mental health treatment Treated negative experience?

Have you been hospitalized for mental health treatment before?  Yes  No If YES, describe.

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Reason for inpatient Dates Treated By Whom (Where) Was it a positive or

mental health treatment negative experience?

Past psychotropic medications: If you have ever taken any of the following medications, please, indicate
the dates a d ho helpful the edi atio as. (If you a ’t re e er 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: Writing Level:

 Cannot read  Cannot write

 Can read some  Can write some

 Can read very well  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
Signature of Person
Patientto
orbe Served: _______________________________________
Guardian Date: ________

Do not write below this line.

For Clinic Use Only: Admission Date (the date of the FIRST appointment): ______________

 Intake form has been reviewed Cli icia ’s i itials: ____________

 Initial assessment session or initial psychiatric evaluation has been completed with the person to be
served. (*See session note or psych. eval.) Cli icia ’s i itials: ____________

 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 byy the
iMindSupport
MentalSolutio
Healths’and Wellness.
Outpatient Mental Health Clinic. Cli icia ’s i itials: ____________

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 byy the Support
iMind MentalSolutio
Healths’and Wellness.
Outpatient Mental Health Clinic AND a referral has been made to _______________________________.
Cli icia ’s i itials: ____________

Cli i ia ’s Pri ted Na e a d Title: _________________________________________________________

Cli i ia ’s Sig ature: ______________________________________ Date: _____________________

Reviewed by: __________________________________________ Date: _____________________

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