Intake screening form Brief Client Intake Screening Form All information on this form is strictly confidential; Please note this form is not used as a diagnostic tool. This form is to aid in determining appropriate services. A more comprehensive intake/evaluation will be administered once you are established as a client. Name * Preferred Name Date * Best Contact Number * Best Time to Call * A.M. Mid-day P.M. Is it ok to leave a voicemail at this number? * Yes No Date of Birth * Age * Sex Gender Identity Sexual Orientation Ethnicity Hispanic or Latino or Spanish Origin Not Hispanic or Latino or Spanish Origin Race American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Preferred Language * Address Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Occupation * Marital Status * Single Married Widowed Divorced Separated Employment Status * Student Employed Full Time Employed Part-Time Employed Per-Diem Unemployed Disabled Highest Education Completed * Religion Spiritual, Energy or Scientific Beliefs Primary Care Physician * Phone * Are you willing to give permission for provider collaboration? * Yes No Current Therapist/Counselor/Provider: * Phone * Are you willing to give permission for provider collaboration? * Yes No How Did You Hear About Us? * What brings you to seek mental health treatment or consultation? * Current Medication Please list any CURRENT medications you are taking (please include over the counter medications, herbals and any nutritional supplements) Medication Date Started/Stopped Dosage Response/Side Effects Provider Facility plus1 Add minus1 Remove Symptoms Please check the symptoms below that you have been experiencing over the past few weeks. Emotional Concerns Sadness Irritability Jealousy Guilt How difficult has sadness made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult How difficult has irritability made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult How difficult has jealousy made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult How difficult has guilt made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult Worry Anger Hopelessness Feeling on edge How difficult has worry made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult How difficult has anger made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult How difficult has hopelessness made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult How difficult has feeling on edge made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult Not enjoying life How difficult has not enjoying life made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult Numbness How difficult has numbness made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult Physical Concerns Fatigue Muscle tension Restlessness Insomnia How difficult has fatigue made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult How difficult has muscle tension made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult How difficult has restlessness made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult How difficult has insomnia made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult Avoidance Excessive energy Racing heart Alterations in sleep How difficult has avoidance made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult How difficult has excessive energy made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult How difficult has a racing heart made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult How difficult has alterations in sleep made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult Changes in libido How difficult has changes in libido made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult Behavioral Concerns Panic attacks Binging Purging Crying How difficult has impulsivity made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult How difficult has binging made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult How difficult has purging made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult How difficult has crying made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult Impulsivity Nightmares Changes in appetite Cutting/self-harm How difficult has panic attacks made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult How difficult has nightmares made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult How difficult has changes in appetite made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult How difficult has excessive talking made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult Excessive talking How difficult has cutting/self-harm made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult Restricting meals How difficult has restricting meals made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult Cognitive Concerns Distractibility Forgetfulness Racing thoughts Flashbacks How difficult has distractibility made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult How difficult has forgetfulness made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult How difficult has racing thoughts made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult How difficult has flashbacks made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult Desire to hurt others Paranoia Difficulty concentrating Thoughts of self-harm How difficult has a desire to hurt others made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult How difficult has paranoia made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult How difficult has difficulty concentrating made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult How difficult has thoughts of self-harm made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult Poor judgment How difficult has poor judgment made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult Hallucinations How difficult has hallucinations made it for you to do your work, get along with others or take care of things at home? 1 2 3 4 5 Not Difficult at All → Extremely Difficult Psychiatric History Please list any prior counseling/mental health treatment/medication management: Dates Provider Reason plus1 Add minus1 Remove Have you ever received inpatient psychiatric treatment? Yes No Dates Facility Reason Please list all PAST psychiatric medication Medication Date Started/Stopped Dosage Response/Side Effects Provider Facility plus1 Add minus1 Remove Physical Symptoms Circle any that were a problem for you in the last month: Checkboxes Headaches Sexual problems Fatigue Nausea Stomach aches Dizziness Diarrhea Fainting Chills/Hot flashes Shortness of breath Heart pounding Vision changes Blackouts Sweating Trembling/Shaking Muscle spasms Numbness Chest pains Rapid heart beat Mouth muscle/Joint pain Muscle tension Tics/Twitches Skin problems Choking sensations If Female: Are you on any form of birth control? Yes No Are you, or is there a chance you might be, pregnant? Yes No Are you planning on becoming pregnant in the next year? Yes No Additional Assessment Please check appropriate boxes Been so distressed you seriously wished to end your life? * No Yes Recently (1-3 months) Today Attempted to kill yourself in the past? * No Yes Recently (1-3 months) Today Having thoughts of currently harming or killing yourself? * No Yes Recently (1-3 months) Today Hurt someone or destroyed property on purpose? * No Yes Recently (1-3 months) Today Slapped, kicked, punched someone with intent to harm? * No Yes Recently (1-3 months) Today Been arrested or detained for violent behavior? * No Yes Recently (1-3 months) Today Been to jail for any reason? * No Yes Recently (1-3 months) Today Been on probation for any reason? * No Yes Recently (1-3 months) Today Medical History Most recent Height * Weight * lbs. Blood Pressure EKG Any abnormalities? Yes No Physical Labs Any abnormalities? Yes No List All Medical Conditions List Any Allergies to Medications/Foods Alcohol Use Regularly use alcohol (more than twice per week)? * Yes (in the past) Yes (recently) No Had trouble (legal, work, family) because of alcohol? * Yes (in the past) Yes (recently) No Felt you should cut down on your drinking? * Yes (in the past) Yes (recently) No Been annoyed by people criticizing your drinking? * Yes (in the past) Yes (recently) No Felt bad or guilty about your drinking? * Yes (in the past) Yes (recently) No Ever had a drink first thing in the morning? * Yes (in the past) Yes (recently) No Substance Use/Abuse Use medications (other than over the counter) not prescribed to you? * Yes (in the past) Yes (recently) No Taken more than the recommended daily dose of an over the counter medication? * Yes (in the past) Yes (recently) No Taken more than the prescribed dose of your prescription medication? * Yes (in the past) Yes (recently) No Taken or used any illegal substance? * Yes (in the past) Yes (recently) No Used any product or other means to alter your state of being/consciousness? * Yes (in the past) Yes (recently) No Smoke or chew tobacco regularly? (Including vaping) * Yes (in the past) Yes (recently) No Habits How many caffeinated drinks do you have per day (coffee, tea, sodas)? * How often do you exercise per week? * Preferred Exercise * Do you have problems with gambling? Yes No Do you have other potentially harmful habits you want to change? Yes No If so, what? Goals for Treatment What are your goals for treatment? In other words, what things would you like to see change or be different about yourself? If you are human, leave this field blank. Submit
