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Adult Intake Form

Personal Information
Date
Date
Enter today's date/date of submitting this form
Name *
Name
Date of Birth
Date of Birth
Address
Address
Home Phone
Home Phone
Work Phone
Work Phone
Mobile Phone
Mobile Phone
In Case of Emergency
Contact Number
Contact Number
Family History
Has anyone in your family (blood relative) suffered from emotional, problems, nervous problems, depressions or other stress conditions? If so, please list the family member(s) and briefly describe the problem.
Has anyone in your family (blood relative) had problems with alcohol? If so, please list the family member(s) and briefly describe their problem
Has anyone in your family (blood relative) had problems with drugs? If so, please list the family member(s) and briefly describe the problem.
Do any medical problems run in your family? If so, please list briefly and describe these problems
Has anyone in your family ever attempted or committed suicide? If so, please list briefly and describe the incident.
Father
If deceased, when did your father die?
If deceased, what was the cause of death?
How much education did he have?
What type of work did he do?
Mother
If deceased, when did your mother die?
If deceased, what was the cause of death?
How much education did she have?
What type of work did she do?
Siblings
Personal History
Please list in order all the cities and states in which you have lived and include the number of years (or age) you resided in each city.
Socioeconomic Environment
Please choose the socioeconomic environment in which you grew up:
Did you suffer from any traumatic experiences as a child? If so, please describe these.
Juvenile Behavioral Problems
Did you have any juvenile behavioral problem(s)? Please check any problem(s) that you have experienced.
Education
Social History
If so, how were you abused?
If so, please specify which child(ren) and explain the problem(s)
Occupational History
Please list your jobs, starting with the first job and going through to your most recent job. Also list next to each job how many years you were employed in that position.
Present Living Situation
Substance Use History
Do you use or have you used drugs? Have you quit using drugs? If you still use drugs, complete the following list:
Have you ever been involved in a substance abuse, alcohol treatment or detoxification program? If so, please describe when and where.
Medical History
Please list any medical problems that you have and when these conditions were diagnosed or discovered.
Please list all operations that you have had starting with any operations that you may have had as a child. Also list when these procedures were performed.
Please list any allergies to medications that you have experienced.
Have you ever had a head injury in which you were knocked unconscious? If so, please list your age at the time of the injury and how long you were unconscious.
Please list all your present medications. Include the amount (milligrams), how often you take it, how long you have taken it and the doctor who prescribes it.
Psychiatric History
Have you ever received any psychiatric, psychological, emotionaltreatment/counseling or hospitalization in the past? If so, list the year(s) or your age when this treatment was provided and how often the treatment was provided.
Have you ever been prescribed psychiatric medicines (like an antidepressant or nerve pill?) If so, list the year(s)/age, medication, and how often you take the medication