Adult Clinical Intake Questionnaire

AUBREY K. EWING, PH.D. & ASSOCIATES, P.A.
1230 So. Federal Hwy, Boynton Beach, FL 33435

ADULT CLINICAL INTAKE QUESTIONNAIRE

The questions on the following pages ask you to provide information about why you are seeking counseling or other psychological services. They ask about your general emotional and physical health, pertinent history, how you are feeling now, and what concerns are most important to you. The questionnaire gives your doctor/therapist a head-start in understanding how to be of help to you.

This information will become part of your confidential record with this office and will not be released to anyone without your written permission. Your answers to these questions are considered protected health information (PHI) and are relayed to our office by a secure, HIPAA compliant process. We are committed to ensuring your privacy and protecting our confidential relationship.

Name

Email address to send confirmation of form receipt

example@example.com

Date of birth

Date

Age

Gender

Primary physician

Marital status

Name of spouse/partner

Your occupation

Employer/school

What is the primary reason for your visit at this time?

List the three behaviors or symptoms that concern you the most. Start with the most troubling first and work your way down.

When did you first notice having these behaviors or symptoms?

What are you most worried might happen if things continue as they are?

What are the most stressful things in your life that are affecting you right now?

Did you ever have similar behavioral or emotional problems that concerned you when you were younger?

If yes, please describe these problems, when they occurred, and what was done about them?

Have you ever seen anyone for help with behavioral or emotional problems?

If so, how old were you at the time?

Who did you see?

Did it help?

Have you ever taken medicines to help with behavioral or emotional problems?

If yes, how long ago?

Please list all the medications you have taken in the past (not your current meds):

List any medical problems for which you are currently being treated. Please indicate if a problem has been ongoing requiring regular or periodic care.

List any past hospitalizations you have had for medical, surgical, chemical dependency, or psychiatric reasons.

List any medications to which you are allergic or that you could not take due to intolerable side effects.

Please list all medications you are currently taking. Include birth control, vitamins, and over the counter drugs. Please include the name of the prescribing doctor.

FAMILY HISTORY

Has any relative on either parent's side of the family had any of the following?

Nervousness or panic

Other

Depression

Other

Obsessive-compulsive problems

Other

Bipolar disorder (manic depressive illness | cycling mood)

Other

Suicide

Other

Alcohol or drug problems

Other

Police record (arrests, jail)

Other

Schizophrenia

Other

Intellectual disability (formerly mental retardation)

Other

Developmental problems (autism spectrum disorder)

Other

Learning disoder (specific LD, dyslexia, other)

Other

Attention problems (ADD, ADHD)

Other

Tourette's or other tic problems

Other

Other conditions or more detail about answers above

HISTORY OF BEHAVIORAL OR EMOTIONAL EVENTS AND PROBLEMS

Please place a check in front of all that apply to you:

I experience the following at home, work, or school:

The following describe traits that I have or things that I've done:

Check all of the following that apply to you:

Provide details about alcohol or other substance use/abuse (amount, frequency, etc.) that will clarify the extent of your use

I have had a period of two weeks or longer (now or in the past) when I:

I have had a period of at least one week or longer (now or in the past) when I:

The following describe traits I have or things I have experienced:

If you answered "yes" to the question above, how often do you have panic or anxiety attacks?

Please check the following that are true about you:

Have you ever had thoughts or sensory experiences that confused you such as (check the boxes that apply):

Have you ever had biofeedback or neurofeedback training/treatment?

If yes, please describe why you were referred for biofeedback, the type you received to the best of your knowledge, and if it was effective.

Thank your for taking the time to answer these important questions. This information is helpful to the doctor/therapist in understanding your needs and how to best be of help to you.