Language
English (US)
Español
Riddle Psychiatry Intake Form
Today's Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Gender
*
Please Select
Male
Female
Transgender Male
Transgender Female
Gender Queer
Non-Binary
Questioning
Decline to Answer
What pronouns do you prefer that we use when talking about you?
*
Please Select
She/ Her/ Hers
He/ Him/ His
They/ Them / Thiers
Are you Hispanic or Latino? (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish or origin, regardless of race?)
*
Yes
No
Please select the racial category or categories with which you most closely identify:
*
American Indian or Alaska Native
African American
Asian
Native Hawaiian or Other Pacific Islander
White
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
*
Cell Phone Number
*
Email
example@example.com
Preferred Point of Contact
*
Please Select
Home Phone
Cell Phone
Email
Emergency Contact #1
*
First Name
Last Name
Emergency Contact Phone Number
*
Please check the following options as to what information can be shared with your emergency contact:
*
Appointment Information
Billing Information
No Information/ Contact for Emergency ONLY
Other
Emergency Contact #2
First Name
Last Name
Emergency Contact Phone Number
Please check the following options as to what information can be shared with your emergency contact:
Appointment Information
Billing Information
No Information/ Contact for Emergency ONLY
Other
Employment Status:
*
Full-time
Part-time
Not Employed
Retired
Self Employed
Student
Active Military Duty
Pharmacy Information: (Local Pharmacy)
*
Pharmacy:
Street Address
City
State / Province
Postal/ Zip Code:
Pharmacy Phone Number:
*
Pharmacy Information #2: (Mail-Order Pharmacy)
Pharmacy:
Street Address
City
State / Province
Postal/ Zip Code:
Pharmacy Phone Number #2:
Primary Care Physician
First Name
Last Name
Primary Care Physician Phone Number
Permission to speak with Primary Care Physician about treatment?
Yes
No
Current Therapist / Counselor
First Name
Last Name
Therapist's Phone Number
Personal History
Please list the problem(s) which you are seeking help?
*
Current Symptoms
*
Depressed mood
Racing thoughts
Excessive worry
Unable to enjoy activities
Impulsivity
Anxiety attacks
Sleep pattern disturbance
Increase risky behavior
Avoidance
Loss of interest
Increased libido
Hallucinations
Concentration/forgetfulness
Decrease need for sleep
Suspiciousness
Change in appetite
Excessive energy
Excessive guilt
Increased irritability
Fatigue
Crying spells
Decreased libido
Other
Have you ever had feelings or thoughts that you didn't want to live?
Yes
No
Do you currently feel that you don't want to live?
Yes
No
How often do you have these thoughts?
When was the last time you had thoughts of dying?
On a scale of 1 to 10, (ten being strongest) how strong is your desire to kill yourself currently?
Weak
1
2
3
4
5
6
7
8
9
Strong
10
1 is Weak, 10 is Strong
Yes
No
Do you feel hopeless and/or worthless?
Have you ever tried to kill or harm yourself before?
Is there anything that would stop you from killing yourself?
Medical History
Do you have any allergies? (If yes, please list them)
*
Current Weight
*
Current Height in inches
*
List all current prescription medications and how often you take them
*
Current medical problems
*
Past medical problems, nonpsychiatric hospitalization, or surgeries
*
For women only:
Psychiatric History:
Outpatient treatment
Yes
No
If yes, Please describe when, by whom, and nature of treatment
Psychiatric Hospitalization
Yes
No
If yes, Please describe when, by whom, and nature of treatment
Past Psychiatric Medications
If you have ever taken any of the following medications, please indicate the dates and daily dosage.
Have you ever taken it?
Dates
Dosage
Side Effects?
Prozac (fluoxetine)
Zoloft (sertraline)
Luvox (fluvoxamine)
Paxil (paroxetine)
Celexa (citalopram)
Lexapro (escitalopram)
Effexor (venlafaxine)
Cymbalta (duloxetine)
Wellbutrin(bupropion)
Remeron (mirtazapine)
Serzone (nefazodone)
Anafranil (clomipramine)
Pamelor (nortrptyline)
Tofranil (imipramine)
Elavil (amitriptyline)
Tegretol (carbamazepine)
Lithium
Depakote (valproate)
Lamictal (lamotrigine)
Tegretol (carbamazepine)
Topamax (topiramate)
Seroquel (quetiapine)
Zyprexa (olanzepine)
Geodon (ziprasidone)
Abilify (aripiprazole)
Clozaril (clozapine)
Haldol (haloperidol)
Prolixin (fluphenazine)
Risperdal (risperidone)
Ambien (zolpidem)
Sonata (zaleplon)
Rozerem (ramelteon)
Restoril (temazepam)
Desyrel (trazodone)
Adderall (amphetamine)
Concerta (methylphenidate)
Ritalin (methylphenidate)
Strattera (atomoxetine)
Xanax (alprazolam)
Ativan (lorazepam)
Klonopin (clonazepam)
Valium (diazepam)
Tranxene (clorazepate)
Buspar (buspirone)
Other medications?
Family Psychiatric History
Has anyone in your family been diagnosed with or treated for:
Bipolar disorder
Depression
Anxiety
Anger
Suicide
Schizophrenia
Post-traumatic stress
Alcoholabuse
Other
Has any family member been treated with a psychiatric medication? If yes, who was treated, what medications did they take, and how effective was the treatment?
Exercise Level
Do you exercise regularly?
Yes
No
How much time each day do you exercise?
Check if you have ever tried the following
Methamphetamine
Cocaine
Stimulants (pills)
Heroin
LSD or Hallucinogens
Marijuana
Pain killers (not as prescribed)
Methadone
Tranquilizer/sleeping pills
Alcohol
Ecstasy
Other
How many caffeinated beverages do you drink a day?
Tobacco History
Have you ever smoked cigarettes?
Yes
No
How many packs per day?
How many years?
Family Background and Childhood History:
Were you adopted?
Yes
No
Where did you grow up?
List your siblings and their ages:
Did your parents divorce?
Yes
No
Do you have a history of being abused emotionally, sexually, physically or by neglect? If yes, please describe when, where and by whom.
Highest grade completed?
Are you currently:
Working
Student
Unemployed
Disabled
Retired
Are you currently:
Married
Partnered
Divorced
Single
Widowed
Do you have any children?
Yes
No
Please list ages and gender:
Have you ever been arrested?
Yes
No
Additional information
Signature
Guardian Signature (if under age 18)
Save
Submit
Should be Empty: