Adult New Patient Intake Form

Please complete this form prior to arriving for your initial/first appointment with Dr. Casey.  You can either print it out directly from this webpage and fill it in by hand, or alternately can download it and type your answers either into a Word/OpenOffice document or fill out a PDF to be printed (pdf can be typed into but answers cannot be saved).  If you have an appointment already scheduled, expect to receive your intake paperwork electronically - you will be emailed a secure link to complete it online.
Thank you for taking the time to complete this document. This history form is designed to give you an opportunity to provide us with a wide variety of background information. Please read the questions carefully and answer them as frankly as possible. The information will help us to help you. Completion of this form is considered the first step in the evaluation and treatment process. By answering these questions in advance, our staff will be able to spend more time during the initial interview discussing the issues that are most important to you, as you begin mental health treatment.
 
CONFIDENTIAL
FOR PROFESSIONAL USE ONLY
 
 
DEMOGRAPHICS
 
 
Date / Time you are completing this form: ____________,
for visit scheduled on ______________ (date/time).
 
NAME OF THE PERSON COMPLETING THIS FORM:  ____________________________________________________
 
RELATIONSHIP TO THE PATIENT:  ___________________________________________
 
 
PATIENT'S NAME: ____________________________________  
 
DATE OF BIRTH:   ___ / ___ / ______                                           CURRENT AGE: ________    
 
SPOUSE’S/PARTNER’S NAME: _______________________ 
 
PARTNER'S DATE OF BIRTH or AGE:  
 
CURRENT RESIDENCE/ADDRESS:
(Number, Street, Apt. #) (City, State) (Zip Code)
 
_________________________________________________________
 
_________________________________________________________
 
MAILING ADDRESS, IF DIFFERENT:
 
_________________________________________________________
 
 
PHONE:
 
Cell ____________________      Home _____________________
 
Work __________________      Other _____________________
 
Okay to leave a message at the phone numbers?
 
Yes________ No _________
 
 
E-mail: _________________________________________________
 
 
Preferred Method of Communication:
 
___ Phone call / Voicemail
 
___ Text messages on Cell*
 
___ Email*
 
*Please be aware there is no way to guarantee confidentiality when using these methods of communication.
 
BIOLOGICAL SEX:        Male ______     Female ______               
 
GENDER: ______________________________________________
 
MAIDEN NAME (if applicable) ________________________
 
LAST 4 OF YOUR SOCIAL SECURITY:     ___ ___ ___ ___          
 
CITIZENSHIP: ____________________
 
EMPLOYER’S NAME (S) & ADDRESS (ES): (Also include all other sources of income)
 
 
 
 
ESTIMATED ANNUAL FAMILY INCOME: ______________________________
 
Do you currently have trouble affording your medications? Yes _________ No __________
 
 
MEDICAL INSURANCE (S): (Fill in company names and policy numbers, if you have them handy) **Skip this if you have provided this information previously**
 
 
 
 
 
What mental health or psychiatric conditions have you been diagnosed with in the past (list diagnosis and date you were first diagnosed):
 
 
 
 
 
Briefly describe the mental health reason(s) that brought you our clinic today. The details of what has brought you in will be discussed with your clinician, so if possible, please attempt to summarize.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
How long has this been a problem or when did it worsen?
 
 
 
 
How did you hear about our clinic? ___________________________________________________
 
If you have a current Psychiatrist and/or Counselor / Therapist, please list below:
 
Psychiatrist: location and phone number:
 
 
Therapist: location and phone number:
 
 
If you have ever seen a psychiatrist, psychologist, social worker, counselor, member of the clergy, family doctor, etc., for this, or for similar problems, please list the following:
 
Professional’s Name/Address         Dates seen (from _____/to _____)       Problem/Reason for Treatment
 
1.
 
2.
 
3.
 
4.
 
5.
 
 
If you have ever been hospitalized for psychiatric or medical conditions, please list the following:
 
Hospital’s Name/Address                  Dates seen (from _____/to _____)       Problem or Reason for Admission
 
1.
 
2.
 
3.
 
4.
 
5.
 
 
If you have had prior mental health treatment, what type of therapy, services, and/or medications did you find to be the most helpful?
 
 
 
What new approaches or services do you feel would be of the most help to you, if those services are available? (specific therapies, respite care, support groups, drop-in-center, intensive case management, outpatient therapy, etc.)
 
 
 
Please list all medications (prescriptions, over-the-counter, herbals or supplements) you are using now, including dosages and times you take the medications:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If you have any ALLERGIES or have had bad reactions to any medications, please list them here and describe the reaction:
 
 
 
 
 
If you have ever used tranquilizers, antidepressants, antipsychotics or other medications for mental health related problems, please list them here and comment on the reason they were discontinued:
 
 
 
 
 
 
 
 
 
 
MEDICAL HISTORY
 
Please check all of these that you have now and/or have had in the past. If it occurred in the past, please indicate the age when it was happening.
Pres. Past Age                                                                               
_____ _____ _____ crying spells
_____ _____ _____ arthritis
_____ _____ _____ head injury
_____ _____ _____ asthma
_____ _____ _____ headaches
_____ _____ _____ back problems
_____ _____ _____ fainting / dizziness
_____ _____ _____ bed-wetting / soiling
_____ _____ _____ seizures
_____ _____ _____ bladder problems
_____ _____ _____ unconsciousness
_____ _____ _____ bowel problems
_____ _____ _____ loss of appetite
_____ _____ _____ cancer
_____ _____ _____ weight gain / loss
_____ _____ _____ diabetes
_____ _____ _____ high fevers
_____ _____ _____ heart trouble
_____ _____ _____ hives / rashes
_____ _____ _____ hepatitis / jaundice
Pres. Past Age  
_____ _____ _____ blood pressure (high / low)
_____ _____ _____ kidney trouble
_____ _____ _____ chest pain / pressure
_____ _____ _____ liver trouble
_____ _____ _____ shortness of breath
_____ _____ _____ rheumatic fever
_____ _____ _____ gynecological problem
_____ _____ _____ stomach problems
_____ _____ _____ premenstrual syndrome
_____ _____ _____ stroke
_____ _____ _____ nightmares
_____ _____ _____ thyroid problems
_____ _____ _____ night sweats
_____ _____ _____ tuberculosis
_____ _____ _____ pos. test for AIDS antibody
_____ _____ _____ unusual bleeding
_____ _____ _____ sexual dysfunction
_____ _____ _____ skin problems
_____ _____ _____ other _____________________
_____ _____ _____ other _____________________


Please use this area to comment on any of the items listed above, and on any other serious accidents, operations, or illnesses:









Please check the following if it applies to you and describe details in the space provided:

_____ Sleep Difficulties
 
Details:
_____ can’t fall asleep
_____ can’t stay asleep through the night
_____ wake up too early
_____ sleeping too much
 
 

_____ Eating Difficulties
 
Details:
_____ eating too much
_____ eating too little
_____ binge eating and/or purging
 

_____ Difficulties maintaining a daily routine
 
Details:


Please list the name(s), address(es), and phone numbers of your primary care provider(s) or clinic(s) you use most often:



Please list the names and addresses of any other doctors you are seeing/have seen:

1.

2.

3.
 

Please give the name, address, and phone number of the pharmacy you prefer to use:


Please describe any especially frightening or disturbing events that you have experienced, such as automobile accidents, fires, deaths, violence, crime victimization, and illnesses:





Has anyone ever physically, emotionally, or verbally abused you?   Yes        No


 
FAMILY HISTORY

Please list Name, Age, Occupation, & Current Location

Father __________________________________________________

Mother ____________________ ____ ________________________

Bros&Sisters  
____________________ ____ _________________________ _______
____________________ ____ _________________________ _______
____________________ ____ _________________________ _______
____________________ ____ _________________________ _______
____________________ ____ _________________________ _______
 

Please use this space to comment on your family while you were growing up, noting any rough spots, such as parental separation/divorce/remarriage, and if someone other than your natural parents raised you, note the name(s):






If you have lived in any foster homes or residential placements, please list the name(s) and address(es):


Check any of the following that occurred (or are occurring now) in your family and give a brief description of those checked in the space below:
 
1. Physical abuse _____
2. Violent argulents/fighting _____
3. Child abuse _____
4. Sexual abuse _____
5. Chronic illness _____
6. Alcohol abuse _____
7. Drug abuse _____
8. Suicidal behavior _____
9. Involvement with a cult _____
10. Involvement with a gang _____

If any members of your family have been treated for mental or emotional problems, or substance abuse issues, please explain the circumstances here:
 
 
 
 

MARITAL AND SOCIAL HISTORY

Current Relationship Status:

Single _____                                  Separated _____

Married _____                              Divorced _____

Living w/ Someone _____      Widowed _____

Dating _____                                 Other _____
 

Please provide some information about your past and present relationships with others and note any current relationship problems you may be having:






If you have children, please list the following information:

Name          Age          Lives with…                School grade/occupation

1. ________________ ___ ___________________ _______________
2. ________________ ___ ___________________ _______________
3. ________________ ___ ___________________ _______________
4. ________________ ___ ___________________ _______________
5. ________________ ___ ___________________ _______________
6. ________________ ___ ___________________ _______________
 
 
Please list the names, ages, and relationships to you of those currently living with you and not listed above, including all family members, friends, and so on.

Name
DOB/Age
Relationship
 

Name
DOB/Age
Relationship
 
 
 
 
 
 
 
 


Please check what language(s) is (are) spoken and/or written in your home?

English: _____ spoken _____ written

Spanish: _____ spoken _____ written

Other Language(s):
 
___________________________       _____ spoken _____ written
 
___________________________       _____ spoken _____ written
 

If you are actively involved in church, temple, mosque, or other spiritual activities, please give the name of this organization and a brief description of the activities:


What do you enjoy doing in your spare time? Include hobbies, interests, and anything else that helps you relax.
 


Do you feel you make friends easily? Yes _____ No _____

Do you feel that you generally trust people fairly easily? Yes _______ No ________

Briefly describe any difficulties you may have in dealing with people:
 
 



Who is aware you are beginning mental health services? (e.g. family, friends, and/or employer)

If others are aware, what is their attitude about it?

What strengths can you list that will help in resolving the issues you have noted?
(e.g., family supports, friendships, personal insights, faith, etc.)





Please explain what type(s) of transportation you use: (Do you drive, take buses, or have other transportation available?)
 

EDUCATIONAL HISTORY

Highest school grade or education level completed? _____________________
 
GED? Yes _____ No _____

                                           School Name           Location                 Degree                  Year
 
High School

College

Grad. School

Please list any other specialized education/training you have received:



If you had any trouble in school with either academic subjects or behavior, or any know learning or developmental delays/concerns please describe the problem(s) here:


If you received any special awards or honors in school, please note them here:





 
OCCUPATIONAL HISTORY

Present occupation & employer:
 
______________________________________________________

How long have you had this job? ____________________
 

Please describe the nature of your duties/responsibilities and note any recent changes that have been stressful (include promotions, demotions, awards, or any disciplinary actions):


If your current mental health problems or medications are interfering with job performance, please comment upon that here:

How well do you get along with fellow workers? ______________________________

How well do you get along with supervisor(s)? ______________________________

How many different jobs have you held in the last five years? _____________________

What other jobs have you held since you began working?



Please list any specialized job training you have received or skills you have mastered:

How would you describe yourself in relationship to spending, saving, and managing money?


 

MISCELLANEOUS
 

If you use tobacco, how much and what type do you use daily?



If you have ever used alcohol, when, where, how much, and what type do you (did you) drink?



If you have ever used street drugs (marijuana, cocaine, LSD, etc.) or abused prescription medications, please list the following:
 

Type of drug          Amount         Frequency    Most Recent Usage







If you have ever been treated for substance abuse, please list the name(s) and address(es) of the treatment sites(s):

Name/Address             Dates (From /to )               Problem

1.

2.

3.

If you consume caffeine (in coffee, tea, colas, etc.), how much do you consume daily?

Do you have any history of aggressive behavior or legal / criminal charges related to assaults? Yes No
If so, please describe:

Do you have any history of fire setting?      Yes      No
If so, please describe:
 

If you have ever been arrested, please check all that apply:

Juvenile arrest record          Yes _____ No _____

Adult arrest record                Yes _____ No _____

Currently on probation        Yes _____ No _____

Currently on parole               Yes _____ No _____

If on probation/parole, list the name, address, and phone number of the P.O.:

If applicable, please describe the arrest record here:

 
 
 

MILITARY HISTORY

Have you ever been in the military?

Yes _____ No _____ (If no, skip to the next section)

If yes, which branch? _______________________________

Officer or enlisted? _________________________________

Length of service? (month and year)

From _________________ To ________________
 

If you were honored or promoted while in the service, please explain here:
 


If you were disciplined or demoted while in the service, please explain here:
 
 

If you were in treatment while in the service, please explain here:

Do you have a “service connected” disability?
Yes _____ No _____
 

If yes, please explain here:


Date and type of discharge:
 
 
 
OTHER AGENCIES / SERVICES
 

If you are involved with any other agencies/services or you are trying to apply for benefits, please check them off (or add them) below and fill in the name and phone number of the contact person:

Agency/Service                Contact Person       Phone Number

_____ Adult Education (________________________) ____________________ _______________
_____ Children & Youth Services (________________) ____________________ _______________
_____ CHIPPS, ICM, or RC (____________________) ____________________ _______________
_____ Clubhouse (____________________________) ____________________ _______________
_____ Consumer Organization (__________________) ____________________ _______________
_____ Drop-in-Center (_________________________) ____________________ _______________
_____ Drug & Alcohol (_________________________) ____________________ _______________
_____ Law Suits/Legal Action (___________________) ____________________ _______________
_____ Mental Health Program (___________________) ____________________ _______________
_____ Public Assistance (or Medical Assistance) ____________________ _______________
_____ Social Security (e.g. SSD or SSI) ____________________ _______________
_____ Support Group (_________________________) ____________________ _______________
_____ Veteran’s Administration ____________________ _______________
_____ Workman’s Compensation ____________________ _______________
_____ Other (________________________________) ____________________ _______________
 

Please comment on any of these issues here:

 


Please review your answers and, if there is anything else you feel would be important, please include it here:









Thank you for taking the time to fill out this form.  By signing below, you certify that the information
 
provided above is true and complete to the best of your abilities:
 
 
 
 
_______________________________________________________
Patient Signature
 
 
______________________________________________________
Printed Name
 
 
______________________________________________________
Date / Time of Signature

Chapel Hill - Chatham North Office
117 Hidden Valley Drive
Chapel Hill, NC 27516

North Raleigh Mental Health and Wellness
920 Paverstone Dr, Suite D
Raleigh NC 27615