Clinical Intake Form – Adult Date MM slash DD slash YYYY Name* First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Social Security NumberHome Phone*Cell PhoneEmail Address* *Note: Email correspondence is not considered a confidential form of communication.Date of Birth* MM slash DD slash YYYY AgeRaceMarital Status Single Married Living Together Separated Divorced Widowed Do you have children? Yes No Number of childrenChildren's Names and AgesNameAge Education/EmploymentHighest Grade CompletedYearDegree ReceivedCurrent Employer/SchoolJob TitleNumber of years at this jobHave you served in the U.S. Military? Yes No What branch of the military?Dates of ServiceDid you serve any combat deployments? Yes No General Health and Mental Health Information Presenting Problem(s)Please describe your reason for coming in:How would you describe your current physical health? Poor Unsatisfactory Satisfactory Good Excellent Please list any specific health problems (past and present):Any history of surgery? Yes No ListType of SurgeryDate Have you ever had a head injury? Yes No When?Did you lose consciousness? Yes No How long did you lose consciousness for?Please list all medications you are currently taking (prescription and over-the-counter).Any recent changes in functioning/mood?Difficulty sleeping? Yes No Please describeDifficulty eating? Yes No Please describe:How would you describe your current mood? (Please check all that apply) Cheerful Sad Depressed Apathetic Anxious Calm Angry Frustrated Irritable Have you ever been psychiatrically hospitalized? Yes No When?Where?Reason for hospitalization Have you ever received therapy or counseling in the past? Yes No When?With whom? Do you have any history of suicidal ideation? Yes No When?Do you have any history of homicidal ideation? Yes No When?Do you currently have thoughts of wanting to harm yourself? Yes No Do you currently have thoughts of wanting to harm others? Yes No Do you have any history of legal problems or arrests? Yes No What were the charges and dates of arrests?ChargesDates of Arrest Do any family members suffer from the following disorders and if so, please identify the family member(s) that suffer from that disorder.Alcohol/Substance Abuse Yes No Family Member(s)Anxiety Yes No Family Member(s)Depression Yes No Family Member(s)Eating Disorder Yes No Family Member(s)Obsessive-Compulsive Disorder Yes No Family Member(s)Schizophrenia Yes No Family Member(s)Bipolar Disorder Yes No Family Member(s)Suicide Attempts Yes No Family Member(s)Do you drink alcohol? Yes No How many per day?How many per week?How old were you when you first drank alcohol?Do you currently use recreational drugs? Yes No What type?Have you any history of recreational drug use? Yes No What type?Have you ever sought alcohol/drug treatment? Yes No When?Where? Do you smoke cigarettes? Yes No Amount per dayWho do you live with? Family Friend Alone Other Which of the following tasks do you do independently? Dress Bathe Household Chores Cleaning Errands Shopping Cooking Driving What outside activities do you participate in?What are your hobbies?Do you pay/manage your own finances? Yes No If not, who does?
