Psychiatric Intake Form (Page 4 of 5) in pdf

Psychiatric Intake Form Page 4

Family Mental Health History:

Identify if there is a family history of any of the following. If yes, indicate the family member's

relationship to you.

Circle

Family Member

Alcoholism/Drug Addiction

Yes/ No

Anxiety/Phobias

Yes/ No

Major Depression/Bipolar (circle)

Yes/ No

Domestic Violence

Yes/ No

Eating Disorders

Yes/ No

Schizophrenia

Yes/ No

Suicide Attempts

Yes/ No

Family of Origin Information:

Parents:

Are both parents still living? Mother___________

Father____________ If not, how and when

did death occur? Mother_____________________

Father_____________________

Was your parents' marriage: (circle) happy

average

unhappy

very unhappy

Was either of your parents previously married?

Mother___________

Father____________

If yes, cause of end of previous marriage (death of spouse or divorce?)

Mother___________________

Father__________________

Was your home disrupted by:

Separation_________

Divorce___________ Death____________

Other_____________ If yes, how old were you? _______Who did you then live with?__________

Mother's Occupation:________________

Father's Occupation:_________________

Siblings:

Please list Name(s), Age(s), Gender, Step/Adopted, Marital Status, # of children, Occupation

___________________________________________________________________________________

Psychiatric Intake Form Page 4

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