Psychiatric Intake Form (Page 5 of 5) in pdf

Psychiatric Intake Form Page 5

___________________________________________________________________________________

Family of Procreation:

Spouse, Partner, or Significant Other (first name):_________________________

Do you have children together? If yes, please list first name(s), age(s),

gender:_____________________________________________________________________________

Do (either of) you have children from previous relationships? If yes, please list first name(s), age(s),

gender, and where they live:____________________________________________________________

Any others who live with you? _________________________________________________________

Are any children deceased? If yes, how and when did this occur? ______________________________

Additional Information:

Are you currently employed? (circle) Yes

If yes, what kind of work?_____________________ Do you enjoy your work?___________________

Do you find your work to be causing stress right now?_______________________________________

What is your educational background? ___________________________________________________

Do you consider yourself to be spiritual or religious? (circle) Yes

Unsure

If yes, please describe: ________________________________________________________________

Thank you for taking the time to complete this intake form. If there is anything else you think I

should know, please describe below:

___________________________________________________________________________________

Psychiatric Intake Form Page 5