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Sphere on Spiral Stairs

Psychiatric History & Intake Form

Please fill out the form below. 

Date of Birth
Month
Day
Year
Gender Identity
Male
Female
Non-Binary
Other
Preferred Pronouns
She/Her
He/Him
They/Them
Other

___

Presenting Concerns

Have you previously worked on this trauma in therapy?
Yes
No
If yes, what kind of therapy?

___

Mental Health History

Have you ever been diagnosed with a mental health condition?
Yes
No
If yes, please specify:
Are you currently experiencing any of the following? (Check all that apply)
Past psychiatric hospitalizations:
Yes
No
If yes, please list dates and reasons:
Have you ever attempted suicide?
Yes
No
If yes, please provide date(s):

___

Past Therapy History

Have you previously worked with a therapist or counselor?
Yes
No

If yes, please provide the following:

Type of Therapy
Was it helpful?
Yes
No
Other

___

Family Psychiatric History

Please check any that apply to immediate family members (parents, siblings, grandparents):

___

Medical History

Allergies (medications, food, environmental):
None
Yes - Please list
Are you currently under the care of a primary care physician?
Yes
No

___

Substance Use

Do you currently use or have a history of using the following?

___

Lifestyle & Health Habits

How would you describe your sleep patterns?
Do you exercise regularly?
Yes
No
What is your diet like?
Do you drink caffeine?
Yes
No

___

Additional Information

Support system (friends, family, community):

___

Consent

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Date
Month
Day
Year

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