How did you hear about us?

What type of therapy are you seeking?

What brings you in?

What would your partner say?

Length of these relationship:

Can you tell me a little bit about yourself and your family/culture/upbringing?

Can you tell me a little bit about what intimate relationships look like for you?

Do you have any dependents?

Therapy before:

Psychiatry before:

Medications (type & dosage frequency):

Alcohol and Drug Use (type & dosage frequency):

Describe use:

Marijuana/Cannabis products:

Do you have a medical marijuana card?

Describe use:

Recreational drugs:

Describe use:

Suicidality:

Ideation:

Describe, including whether ideation has occurred in the last 2 weeks:

Planning

Describe, including whether planning has occurred in the last 2 weeks:

Attempts:

Describe including year(s) of occurrence and outcome:

Means:

Self Harming Behaviours:

Describe, including most recent incident::

Violence Towards Others:

Describe, including most recent incident::

Describe:

Describe:

Experience of life being threatened by person, accident, or natural disaster:

Hospitalizations for Psychiatric Reasons:

Describe, including year of occurrence, diagnosis (if possible) and resulting treatment:

Actions taken concerning above risks:

Religious Affiliation/Denomination:

Occupation:

Preferred Location:

School: (grade/year, graduation date & current GPA):

City Year Employee: (site name, site grade level, & program manager):

Availability:

Clinician assigned:

Initial Appointment:

Client Informed of

Client Informed of 2 business day cancellation policy:

Who did the intake:

Occupation:

Youth worker:

No describe

Yes describe

If City Year Employee: (site name, site grade level, & program manager):

How did you hear about us?

What type of therapy are you seeking? Individual
Couples
Family
Hybrid
Group

What brings you in?

Client stated strengths

Can you tell me a little bit about yourself and your family/culture/upbringing?

Tell me a little bit about your community & social supports

Do you have any dependents?

Therapy before:

Psychiatry before:

Medications (type & dosage frequency):

Alcohol and Drug Use (type & dosage frequency):

Describe use:

Marijuana/Cannabis products:

Do you have a medical marijuana card?

Describe use:

Recreational drugs:

Describe use:

1Suicidality:

Ideation:

Describe, including whether ideation has occurred in the last 2 weeks:

Planning:

Describe, including whether planning has occurred in the last 2 weeks:

Attempts:

Describe including year(s) of occurrence and outcome:

Means:

Access to any weapons, if so type:

1Self Harming Behaviours:

Describe, including most recent incident:

Violence Towards Others:

Describe, including most recent incident:

Physical/Emotional/Sexual abuse in the past:

Describe:

Experience of life being threatened by:

Hospitalizations for Psychiatric Reasons:

Describe, including year of occurrence, diagnosis (if possible) and resulting treatment:

Actions taken concerning above risks:

Religious Affiliation/Denomination:

Preferred Location:

School: (grade/year, graduation date & current GPA):

Availability:

Insurance and/or Sliding scale amount:

Everything below is for Office Staff Only to Complete

Clinician assigned:

Initial Appointment:

Client Informed of Fee:

Client Informed of 2 business day cancellation policy:

Who did the intake:

Youth worker:

Describe if not occupation

How did you hear about us?

What type of therapy are you seeking?

What brings you in?

Suicidality:

Ideation:

Describe, including whether ideation has occurred in the last 2 weeks:

Planning:

Describe, including whether planning has occurred in the last 2 weeks:

Attempts:

Describe including year(s) of occurrence and outcome:

Means:

Violence Towards Others:

Describe, including most recent incident:

Hospitalizations for Psychiatric Reasons:

Describe, including year of occurrence, diagnosis (if possible) and resulting treatment:

Client Informed of

Client Notes

a:

b:

Referral Source

Are you currently on active duty?

Military Branch

Highest Level of Education

Employment status

Are you currently enrolled in school or job training program?

Are you currently enrolled in school or job training program?

Are you currently using?

Routine of administration types:

During the past 30 days, how many days have you used any of the following:

Cocaine/crack

Marijuana/Hashish

Heroine

Morphine

Dilaudid

Demerol

Fentanyl

Percocet

Darvon

Codeine

Tylenol 2, 3, 4

OxyContin/Oxycodone

Non-prescription methadone

Hallucinogens/psychedelics, PCP, LSD, Mushrooms, or Mescaline

Methamphetamine or other amphetamines

During the past 30 days, how many days have you used any of the following:

Benzodiazepines: diazepam, alprazolam, Triazolam, and etizolam

Barbiturates: Metharbital and pentobarbital sodium

Non-prescription GHB

Ketamine

Other tranquilizers, downers sedatives, or hypnotic

Inhalants

Other illegal drugs

Drug of Choice-Diagnosis

Behavioral Health

Children's Services Referral

If Children's Services referral, do you have an active Children's Services case?

# of children that you have

# of children that you have

Crime Justus status

Probation

Parole

PROB 45

Human Trafficking

Is there a history of Sexual Abuse?

Program Placement (Level of Care)

Sober Housing Needed

Sober Housing Provided

Medical Intake Questions

If female, are you pregnant?

Medicated Assisted Treatment (MAT)

Hypertension

Diabetes

STI's

UTI's

Cellulitis

COPD

Asthma

Blood dyscrasia

City

State

Zip Code

County

Is there a history of drug use?

In the past 30 days, where have you been living most of the time?

Are you currently employed?