Mental Health Intake Form (Page 3 of 4) in pdf

Mental Health Intake Form Page 3

Vittoria Donato Grant, LPC NCC | Trauma & Psychotherapy Associates

Past Psychiatric History:

Outpatient Treatment ( ) Yes ( ) No

If yes, please describe when and the nature of treatment:

_________________________________________________________________________________________________

Psychiatric Hospitalization: ( ) Yes ( ) No

If Yes, please describe when and nature of treatment

Have you ever taken any psychiatric medication such as Antidepressants, Mood

Stabilizers, Antipsychotic/Mood Stabilizers, Sedatives, ADHD medications,

Antianxiety medications?

If so, please indicate the dates, the dosage and how helpful they were

Substance abuse

Have you ever been treated for alcohol or drug use or abuse? ( ) Yes ( ) No

If yes, which substance? ___________________________________________________________

If yes, where were you treated and when? ______________________________________

How many days per week do you drink any alcohol? _______________________________

Have you ever felt you ought to cut down on your drinking or drug use? ( ) Yes

() No

Have you ever had a drink or used drugs first thing in the morning to steady your

nerves or get rid of a hangover? ( ) Yes ( ) No

Do you think you may have a problem with alcohol or drug use? ( ) Yes ( ) No

Occupational History

Are you currently: ( ) Working, ( ) Student, ( ) Unemployed, ( ) Disabled, ( ) Retired

How long in present position? _______________________________________________________

Mental Health Intake Form Page 3