Psychiatric Intake Form (Page 2 of 5) in pdf

Psychiatric Intake Form Page 2

How do you think or feel counseling may be able to help?____________________________________

What strengths do you bring with you to counseling?________________________________________

What about weaknesses?_______________________________________________________________

Previous Counseling or Psychiatric Treatment:

Have you ever received mental health services (counseling, psychotherapy, psychiatric care)? Y

(circle)

If yes, please list previous providers, dates, and length of treatment:

Are you currently taking any psychiatric medication? If so, please list below:

(

)

If you need additional space, please write on the back of this form

Medication

Dose

Frequency

Take as prescribed (Y/N)

Have you ever taken psychiatric medication in the past? If yes, please list and provide dates:

Have you ever been hospitalized? If yes, please indicate when, low long you were hospitalized, and the

reason:_____________________________________________________________________________

Health and Wellness:

How would you rate your current physical health? (circle)

Poor

Fair

Good

Very Good

Please describe any health concerns you are currently experiencing:____________________________

___________________________________________________________________________________

Psychiatric Intake Form Page 2