Intake Assessment

Self-Assessment

How would you rate your current PHYSICAL HEALTH?

How would you rate your current MENTAL HEALTH?

How would you rate your current SPIRITUAL HEALTH?

Have you experienced SERIOUS DEPRESSION?

Have you experienced ANXIETY OR TENSION?

Have you experienced FLASHBACKS?

Have you experienced HALLUCINATIONS?

Date of Last Hallucination

Do you have trouble UNDERSTANDING or REMEMBERING?

Do you have trouble CONTROLLING ANGER?

Do you have THOUGHTS of SUICIDE?

Date of Last Suicidal Thought

Have you ATTEMPTED SUICIDE?

Date of Last Suicide Attempt

Mental Health Diagnosis

Acute Stress Disorder

Attention Deficit Disorder (ADD)

Adjustment Disorder

Attention Deficit Hyperactive Disorder (ADHD)

Bipolar Disorder

Borderline Personality Disorder

Dissociative Disorder

Dissociative Identity Disorder

Eating Disorder

Generalized Anxiety Disorder

Insomnia Disorder

Intermittent Explosive Disorder

Mania

Manic Depressant Disorder

Narcolepsy

Obsessive Compulsive Disorder (OCD)

Panic Disorder

Post Traumatic Stress Disorder (PTSD)

Psychosis

Schizoaffective Disorder

Schizophrenia

Severe Depression

Substance Abuse Disorder

Traumatic Brain Injury (TBI)

Other Diagnosis

If "other", please explain.

Substance Abuse

Do you abuse any substances?

If yes, when did you last use?

If yes, what substances do you choose?

Additional Substances Used

Additional Substances Notes

Does your family have a history of substance abuse or mental health problems?

If yes, please explain your family history of substance abuse and mental health problems

Other Health Conditions

Have you had any recent SURGERIES OR INJURIES?

If yes, please explain your recent SURGERIES OR INJURIES

Do you have any PHYSICAL LIMITATIONS?

If yes, please explain your PHYSICAL LIMITATIONS

Do you have any ALLERGIES TO MEDICATION?

If yes, please list and explain your MEDICATION ALLERGIES

Do you have ALLERGIES TO FOOD?

If yes, please list and explain your FOOD ALLERGIES

Do you have any OTHER health conditions or problems?

If yes, please explain your OTHER health conditions or problems

Treatment

How have you been treating your mental health?

Are you taking any MEDICATIONS?

When was the last time you took your meds?

If yes, what medications do you take?

Additional Medications

Additional Medications Notes

Providers

Are you currently under a Doctor's care?

Do you have a Veterans Administration Doctor?

VA Primary Doctor Name

VA Primary Doctor Location

Do you have another Primary Care Doctor?

Other Primary Doctor Name

Other Primary Doctor Location

Criminal History

Have you ever been CONVICTED of a CRIME?

If yes, what was the charge(s)?

Are you on PAROLE or PROBATION?

If yes, please explain DURATION

If yes, please provide your OFFICER CONTACT information

Do you have any upcoming COURT DATES for the next 6 months?

Please provide your court date (if known)

Do you have any outstanding TICKETS or WARRANTS?

If yes, please state COUNTY and OFFENSE

Residency

What is your prior living situation?

First

First Name

Last Name

Phone Number

Alternate Phone Number

Relationship

Street

City

State

Zip

Alternate

First Name

Last Name

Phone Number

Alternate Phone Number

Relationship

Street

City

State

Zip

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Intake Assessment

Service History

Emergency Contact

Self-Assessment

Mental Health Diagnosis

Substance Abuse

Other Health Conditions

Treatment

Providers

Criminal History

Residency

Relationships

Child 1

Child 2

Child 3

Child 4

Child 5

Next of Kin

First

Alternate

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