Carlisle:
Camp Hill:
Please complete this form as best as you can and submit prior to your intake appointment. Please know this form is reviewed during the intake and if not complete prior to your scheduled intake appointment, the appointment will be delayed and may have to be rescheduled.
Part 1 - IDENTIFYING DATA
Name (Last, First, MI)
Birth Date:
Today's Date:
Address:
Home Phone:
Work Phone:
Cell Phone:
Email Address:
Gender: MaleFemaleOther
If "Other," Please Specify:
Part 2 - PRESENTING PROBLEM
What is (are) your reason(s) for coming in today?
How long have you been experiencing these problems?
Have you had difficulties like this before? YesNo
If "Yes," please explain:
Are you having any self-destructive or suicidal thoughts? YesNo
Part 3 - PAST PSYCHIATRIC HISTORY
List any previous psychiatric or substance abuse evaluations, counseling or hospitalizations.
Reason
Location
Dates
Diagnosis (if known)
List any previous psychiatric medication therapy.
Medication
Effectiveness
Side Effects
Discontinued Reason
Have you ever attempted suicide in the past? YesNo
Part 4 - MEDICAL HISTORY
Name and Location of Health Care Provider:
Office Phone of Health Care Provider Office:
List all allergies and reactions to medications:
List all medications that you are currently taking (please continue in Part 18 if more space required):
Name of Drug
Amount Taken (dose)
List all current and past medical or physical problems, including hospitalizations and traumatic injuries:
Are you currently experiencing severe pain, fever, dizziness, or lightheadedness? YesNo
List any over the counter medications:
Herbal Products:
Supplements/Vitamins
Part 4A - PAIN ASSESSMENT
Are you currently experiencing any physical pain? YesNo
(If experiencing pain, please score your pain on a 10 point scale where 0 = no pain and 10 = worst pain imaginable)
Please score your pain: 012345678910
Good pain day: /10
Average pain day: /10
Bad pain day: /10
What do you do to help you manage your pain on severe pain days?
Part 5 - SUBSTANCE USE ASSESSMENT
In the past year, have you ever drunk alcohol or used drugs more than you intended? YesNo
In the past year, have you felt you wanted or needed to cut down on your alcohol or drug use? YesNo
What, if any, recreational or illicit drugs or medications have you used recently or in the past?
Did you ever find that you needed to drink a lot more or use more drugs in order to get an effect, or that you could no longer get high on the amount that you were using? YesNoN/A
AUDIT Screening Tool
0
1
2
3
4
Please check the box that most applies to you.
Never
Monthly or Less
2-4 Times Monthly
2-3 Times Weekly
4+ Time Weekly
1. How often do you have a drink containing alcohol?
X
4+ Times Weekly
1-2
3-4
5-6
7-9
10+
2. How many drinks containing alcohol do you have on a typical day when you are drinking?
Monthly
Weekly
Daily or Close
3. How often do you have six or more drinks on one occasion?
4. How often during the last year have you found that you were not able to stop drinking once you had started?
5. How often during the last year have you failed to do what was normally expected of you because of drinking?
6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
7. How often during the last year have you had a feeling of guilt or remorse after drinking?
8. How often during the last year have you been unable to remember what happened the night before because of drinking?
Yes, but not in the last year
Yes, during the last year
9. Have you or someone else been injured as a result of your drinking?
Yes, but not in last year
10. Has anyone been concerned about your drinking or suggested that you should cut down
Total AUDIT Score
Column 0
Column 1
Column 2
Column 3
Column 4
Tobacco Use
Do you smoke or use tobacco products? (If no, please go to the next section) YesNo
What do you smoke or use?
CigarettesSnuffCigarsPipe
If other than those listed, please specify:
How much do you use in a day?
How long have you been using tobacco products?
Do you wish to quit? YesNo
Caffeine Use
How many caffeinated beverages do you consume per day on average?
Do you ever feel irritable, jumpy or nervous because of your caffeine use? YesNo
Does caffeine use impair your sleep? YesNo
Part 6 - FAMILY PSYCHIATRIC HISTORY
Relationship
Problem/Diagnosis
Hospitalized
Medications Prescribed?
Hospitalized?
YesNo
Have there been any deaths or suicidal behavior in your family? YesNo
Part 7 - PSYCHOSOCIAL/DEVELOPMENTAL HISTORY
Where were you born?
Who raised you?
Both ParentsMotherFatherOther FamilyFoster Parent(s)Adoptive Parent(s)Other
If "Other," please explain:
Were there any complications at birth? YesNo
How many siblings do you have and what number child were you?
What was it like in your childhood home?
LovingComfortableSupportiveChaoticAbusiveOther
What type of discipline was used in your childhood home?
Did you have any developmental delays or problems?
Have you ever been physically, sexually or emotionally abused?
Part 8 - CURRENT FAMILY RELATIONSHIP ASSESSMENT
Marital Status SingleMarriedDivorcedSeparatedWidowed
If married, for how long?
If married, are you currently having any stressors or problems in your marriage?
YesNoN/A
Have you been married previously?
Do you have any concerns about domestic violence or abuse?
Have you or any of your spouses ever been referred to any agency such as Child Protective Services?
Please list all your children: (continue below, if needed)
N/A
Child's Name
Child's Age
Child's Gender
Biological or Stepchild?
Does this child currently reside with you?
BiologicalStepchild
Does anyone else reside in your household?
Are you having any problems with your children?
If "Yes" to either question, please explain:
Part 9 - RISK ASSESSMENT
Are there any firearms in your home?
Is there any history of domestic violence in your home?
Do you have a history of suicidal or self-destructive thoughts or behaviors?
Do you have a history of homicidal (harm to others) thoughts or behaviors?
Do you have any other safety concerns at this time?
Part 10 - SOCIAL SUPPORT ASSESSMENT
Do you have someone to talk to when you have a problem?
Is there someone you would ask for help if you needed it?
Are you geographically separated from family and friends?
Are you having trouble with your relationships with family, friends or coworkers?
Have you recently withdrawn from family or friends?
Do you belong to any groups or organizations that are supportive and helpful to you?
Part 11 - SPIRITUAL/CULTURAL ASSESSMENT
What is your religious or spiritual affiliation?
How much is your religion or spirituality a source of strength or comfort to you?
Not at allNot very muchSomewhatQuite a bitA great deal
How much is your spiritual community a source of support to you?
Do you have any religious, spiritual or cultural practices that your provider needs to be aware of during treatment?
Part 12 - EDUCATIONAL ASSESSMENT
Highest Level of Education Completed
GED
Some College
High School Year Graduated
4yr College Year Graduated
Masters Year Graduated
Doctoral Year Graduated
Are you currently in school or training? YesNo
Did you repeat or skip any grades? YesNo
Did you attend any special education or gifted classes? YesNo
Did you have any learning disabilities? YesNo
Did you have any disciplinary problems in school? YesNo
Were you ever suspended or expelled? YesNo
If you answered "Yes" to any of the above, please explain:
Part 13 - LEGAL ASSESSMENT
Have you ever been arrested? YesNo
Are you currently on probation or parole? YesNo
Do you presently have any other legal problems? YesNo
Part 14 - SEXUAL ASSESSMENT
Are you experiencing any sexual concerns? YesNo
Have you ever been sexually abused, assaulted or harassed? YesNo
Part 15 - LEISURE, RECREATIONAL AND VOCATIONAL ACTIVITIES
What is your present job?
Are there any problems with your present job?
What do you like to do in your free time?
What limits your ability or desire to participate in leisure and recreational activities?
Part 16 - NUTRITIONAL ASSESSMENT
Height:
Weight:
In the last month have you gained or lost weight without trying? (If yes, please explain below) YesNo
How many meals do you eat per day?
Have you ever had problems with: (If yes, please explain below) Being OverweightBeing UnderweightBinge EatingCompulsive OvereatingVomitingLaxative AbuseExcessive DietingDiureticOther Eating Disorders/Problems
If you answered "Yes" or checked any of the above, please explain:
Part 17 - FINANCIAL ASSESSMENT
Do you currently have any financial problems?
Part 18 - PATIENT DISCLOSURE
Please list any individuals that you consent to have contacted regarding your care:
Spouse (Name):
Gather Further InformationRelease InformationMake Recommendations
Supervisor (Name):
Doctor (Name):
Other Person/Agency (Name):
Please use this space to tell us anything additional that you may feel is relevant or may be important for your provider to know.
Patient Signature:
Date:
