PFHL Mental Health Intake Form
This form provides valuable clinical information for our team about you.  Please complete every question as completely and thoughtfully as possible so we have the most up-to-date information when you arrive for your initial intake appointment.  We appreciate the time commitment that it takes, and we look forward to meeting you soon!
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Email *
Full Name of Patient: *
Date of Birth: *
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Current Local Address: *
Current Local Phone Number: *
Height: *
Weight: *
Recent Blood Pressure: *
Pulse/Heart Rate: *
Describe the problem that prompted you to seek treatment: *
Have you ever had thoughts, made statements, or attempted to hurt yourself? *
Have you ever had thoughts, made statements, or attempted to hurt someone else? *
Have you recently been physically hurt or threatened by someone else? *
Do you have access to guns or weapons? *
Have you had trouble paying attention, completing tasks due to distraction, zoning out while listening, or sitting still since you were a young child? *
Do you seem to be so oppositional or defiant and get upset when things don't go your way that it has caused problems in your life? *
Have you noticed you have periods of sadness or irritability for several days in a row along with decreased energy, social withdrawal, or isolation? *
Rate your average mood over the past two weeks. *
Awful
Amazing
Do you have periods where rage or excitability seem to last for 4 or more days, where you feel the opposite of depressed and are "high on life," have boundless energy and drive, and don't need to sleep to feel refreshed? *
Do you see or hear things that others don't see or hear? *
Do you have unusual beliefs or perceptions that defy logic and your family's beliefs (like you are being watched, followed, or there are government conspiracies against you, for example)? *
Do you have unusual or uncomfortable thoughts, images, or impulses that cause distress (like obsessions that you can't stop thinking about or compulsions that you have to do repeatedly)? *
Do you seem to worry excessively about many things at once, seem to have difficulty controlling the worry, and become irritable or physically affected by the worry (restless, fatigued, tensed muscles, can't sleep, etc.)? *
Rate your average anxiety over the past two weeks. *
None
Extremely High
Do you worry about being in a social or performance situation where you might be studied or judged (eating in public, talking in front of people, etc.) and have an intense fear that you may embarrass yourself? *
(FEMALES ONLY) Do you have consistent significantly increased moodiness, anger, or anxiety before your menstrual periods that seems better soon after the menstrual period starts? *
Have you been exposed to a trauma/event which threatened your life, caused serious injury or physical or mental damage/injury to you or someone you were close to you which still seems to haunt you (such as abuse, neglect, exploitation, violence, family violence, sexual assault, or human trafficking)? *
Do you snore loudly and/or wake up gasping for breath in the middle of the night? *
Have you ever had a sleep study (usually at the hospital or overnight facility where breathing, snoring, heart rate, and brain waves are monitored)? *
Do you have trouble falling or staying asleep, or do you wake up very early and feel tired the next day? *
Do you have an intense fear of gaining weight or becoming fat and starve yourself to prevent that from happening? *
Do you attempt to prevent weight gain by vomiting, using laxatives, fasting, or exercising excessively? *
Do you binge eat large amounts of food, eat to the point of being uncomfortable, and feel guilty or disgusted or depressed afterward? *
Have you always been uninterested in being with others your age, have trouble in social interactions, avoid eye contact, have difficulty with transitions, and/or become unusually preoccupied with objects or unusual routines? *
If there is any additional information you'd like to provide that wasn't covered in the questions above, or anything else you'd like us to know, please state it here:
What medications have you ever taken for depression, to stabilize your mood, for psychosis, to help with sleep, for ADHD, or for anxiety?  The doses, how long you took the medication, and any benefits or side effects is helpful information for us to know. *
Who currently lives with you (with ages and relationship to each person), if applicable? *
Who in your family has depression, anxiety, bipolar disorder, anxiety, OCD, anger problems, schizophrenia, eating disorders, alcohol or drug problems, PTSD, or other mental health diagnoses? *
Who in your family has attempted or completed suicide? *
Did your biological mom have any medical problems during your pregnancy or birth?  If yes, please explain. *
Did your biological mother use any tobacco, medications, street drugs, or alcohol while pregnant with you?  If yes, please explain. *
Did you have any developmental delays in early childhood (crawling, walking, talking, toileting, etc.)?  If yes, please explain. *
What type of outpatient mental health treatment have you had (counseling/therapy, medication management, hospitalizations, drug/alcohol treatment, groups, etc.)?  Provide as much detail as possible. *
Are you currently seeing a therapist or counselor?  If so, who, for how long, and how often? *
How much school have you completed (list degrees, years obtained, and school where completed, if applicable)?  If you are currently in school, where do you go, what are you studying, and what year are you in school? *
Do or did you have an IEP or 504 Plan or receive any type of special education services or extra help while in school? *
If you are currently employed, what do you do for work? *
Are you currently receiving or do you need help finding financial assistance? *
Are you now, or were you ever, in the military? *
Have you used tobacco or nicotine products now or in the past (if yes, please provide details regarding first use, most recent use, heaviest use, and consequences of use)? *
Have you ever drank alcohol (if yes, please provide details regarding first use, most recent use, heaviest use, and consequences of use)? *
Have you ever used marijuana (if yes, please provide details regarding first use, most recent use, heaviest use, and consequences of use)? *
Have you used any other drugs or over the counter medications to get “high” (if yes, please provide details regarding first use, most recent use, heaviest use, and consequences of use)? *
What medical (physical health) problems do you have or have you had in the past? *
What current medications do you take (including over-the-counter medications, vitamins, and supplements - with doses and frequencies)? *
Are you allergic to any medications (if yes, please explain what medication and the reaction that it caused)? *
Who are your biggest supports (family, neighbors, friends, etc.)? *
To what cultural or ethnic group(s) do you belong?  Are there any specific cultural or ethnic beliefs you'd like to be incorporated into your counseling/therapy and/or medical care? *
Are spiritual matters important to you?  If so, would you like spiritual/religious beliefs you'd like to be incorporated into your counseling/therapy and/or medical care? *
Do you have any legal offenses on record or pending in the courts? *
What is your sexual orientation? *
What gender do you identify with (your gender identity)? *
What do you like to do for fun in your leisure time? *
What are your strengths, assets, and positive attributes?  What resources do you use when things get difficult or when others need your help?  What positive things would others say about you? *
Go to https://psychology-tools.com/test/phq-9 and complete the PHQ-9 depression questionnaire.  Record your score in the space provided. *
Go to https://psychology-tools.com/test/gad-7 and complete the GAD-7 anxiety questionnaire.  Record your score in the space provided. *
Go to https://qxmd.com/calculate/calculator_820/insomnia-severity-index-isi and complete the Insomnia Severity Index questionnaire.  Record your score in the space provided. *
OPTIONAL (for patients with possible ADHD only) - Go to https://psychology-tools.com/test/adult-adhd-self-report-scale and complete the Adult ADHD Self-Report Scale questionnaire.  Record your scores for part A and part B in the space provided.
OPTIONAL (for patients with possible OCD only) - Go to https://www.thecalculator.co/health/Yale-Brown-Obsessive-Compulsive-Scale-(Y-BOCS)-Calculator-921.html and complete the YBOCS OCD questionnaire.  Record your score in the space provided.
OPTIONAL (for patients with possible PTSD only) - Go to http://traumadissociation.com/pcl5-ptsd and complete the PCL5 PTSD questionnaire.  Record your score in the space provided.
Please type the full legal name and credentials of the person completing this form.  By doing so, you agree that your typed signature has the same validity and meaning as your handwritten signature.
Date Completed: *
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