Online Behavioral Health Intake Form

Online Behavioral Health Intake Form

Step 1 of 4

Name:
First Middle Last
Alternate Names:
Date of Birth:
Month
Day
Year
Preferred Pronoun:
- He
- She
- They
- Other
Other:
Address:
Street Address Address Line 2 City State ZIP Code
Primary Care Provider:
Phone Number:
Do you give permission for ongoing updates to be provided to your primary care provider?
- Yes
- No
Current Therapist/Counselor:
Phone Number:
What are the problem(s) for which you are seeking help?
Current symptoms:
- Depressed Mood
- Unable to enjoy activities
- Sleep pattern disturbance
- Loss of interest
- Concentration/forgetfulness
- Change in appetite
- Excessive guilt
- Fatigue
- Decreased libido
- Racing thoughts
- Impulsivity
- Increased risky behavior
- Increased libido
- Decrease need for sleep
- Excessive energy
- Increased irritability
- Crying spells
- Excessive worry
- Anxiety attacks
- Avoidance
- Hallucinations
- Suspiciousness
- Other
Other:
Suicide Risk Assessment
Have you ever had feelings or thoughts that you didn't want to live?
- No
- Yes
Do you currently feel that you don't want to live?
- No
- Yes
How often do you have these thought?
When was the last time you had thoughts of dying?
Has anything happened recently to make you feel this uneasy?
On a scale of 1 to 10 (10 being the strongest), how strong is your desire to die?
Would anything make it better?
Have you ever thought about how you would kill yourself?
Is the method you would use readily available?
Have you planned a time for this?
Is there anything that would stop you from killing yourself?
Do you feel hopeless and/or worthless?
Have you ever tried to kill or harm yourself before?
List ALL current prescription medication and how often you take them:
Medication Name Total Daily Dosage Estimated Start Date
Current over-the-counter medication or supplements:
Current medical problems:
Past medical problems, non-psychiatric hospitalizations, or surgeries::
When your mother was pregnant with you, were there any complication during pregnancy or birth?

Past Psychiatric History
Outpatient Treatment:
- No
- Yes
If yes, please describe below
Outpatient Treatment:
Reason Dates Treated By Whom
Psychiatric Hospitalization:
- No
- Yes
If yes, please describe below
Outpatient Treatment:
Reason Dates Treated By Whom
Past Psychiatric Medications:
If you have taken any of these meds, please indicate Dates, Dosage, and how helpful they were to you.
Antidepressants
Prozac (fluoxetine)
Dates Dosage Response/Side Effects
Zoloft (sertraline)
Dates Dosage Response/Side Effects
Luvox (fluvoxamine)
Dates Dosage Response/Side Effects
Paxil (paroxetine)
Dates Dosage Response/Side Effects
Celexa (citalopram)
Dates Dosage Response/Side Effects
Lexapro (escitalopram)
Dates Dosage Response/Side Effects
Effexor (venlafaxine)
Dates Dosage Response/Side Effects
Cymbalta (duloxetine)
Dates Dosage Response/Side Effects
Wellbutrin (buproprion)
Dates Dosage Response/Side Effects
Remeron (mirtazapine)
Dates Dosage Response/Side Effects
Serzone (nefazodone)
Dates Dosage Response/Side Effects
Anafranil (clomipramine)
Dates Dosage Response/Side Effects
Pamelor (nortrptyline)
Dates Dosage Response/Side Effects
Tofranil (imipramine)
Dates Dosage Response/Side Effects
Elavil (amitriptyline)
Dates Dosage Response/Side Effects
Other
Mood Stabilizers
Tegretol (carbamazepine)
Dates Dosage Response/Side Effects
Lithium
Dates Dosage Response/Side Effects
Depakote (valproate)
Dates Dosage Response/Side Effects
Lamictal (lamotrigine)
Dates Dosage Response/Side Effects
Topamax (topiramate)
Dates Dosage Response/Side Effects
Other
Antipsychotics/ Mood stabilizers
Seroquel (quetiapine)
Dates Dosage Response/Side Effects
Zyprexa (olanzapine)
Dates Dosage Response/Side Effects
Geodon (ziprasidone)
Dates Dosage Response/Side Effects
Abilify (aripiprazole)
Dates Dosage Response/Side Effects
Clozaril (clozapine)
Dates Dosage Response/Side Effects
Haldol (haloperidol)
Dates Dosage Response/Side Effects
Prolixin (fluphenazine)
Dates Dosage Response/Side Effects
Risperdal (risperidone)
Dates Dosage Response/Side Effects
Other
Sedative/Hypnotics
Ambien (zolpidem)
Dates Dosage Response/Side Effects
Sonta (zaleplon)
Dates Dosage Response/Side Effects
Rozerem (ramelteon)
Dates Dosage Response/Side Effects
Restoril (temazepam)
Dates Dosage Response/Side Effects
Desyrel (trazodone)
Dates Dosage Response/Side Effects
Other
ADHD Medications
Adderall (amphetamine)
Dates Dosage Response/Side Effects
Concerta/Ritalin (methylphenidate)
Dates Dosage Response/Side Effects
Straterra (tomoxetine)
Dates Dosage Response/Side Effects
Other
Antianxiety Medications
Xanax (alprazolam)
Dates Dosage Response/Side Effects
Ativan (lorazepam)
Dates Dosage Response/Side Effects
Klonopin (clonazepam)
Dates Dosage Response/Side Effects
Valium (diazepam)
Dates Dosage Response/Side Effects
Tranxene (clorazepate)
Dates Dosage Response/Side Effects
Buspar (buspirone)
Dates Dosage Response/Side Effects
Other

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