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Applicant's Information

Scheduling

Intake Form

What are the problem(s) for which you are seeking help?

What are your treatment goals?

Suicide Risk Assessment

If YES, please answer the following.

Past Medical History
List ALL current prescription medications and how often you take them
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For Women Only:

Personal and Family Medical History

Past Psychiatric History

Past Psychiatric Medications

If you have ever taken any of the following medications, please indicate the dates, dosage, and how helpful they were (if you can't remember all the details, just write in what you do remember).

Antidepressants Date Dosage Response/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 (nortriptyline)
Tofranil (imipramine)
Elavil (amitriptyline)
Other Antidepressants Date Dosage Response/Side-effects
Mood Stabilizers Date Dosage Response/Side-Effects
Tegretol (carbamazepine)
Lithium
Depakote (valproate)
Lamictal (lamotrigine)
Topamax (topiramate)
Seroquel (quetiapine)
Zyprexa (olanzepine)
Geodon (ziprasidone)
Abilify (aripiprazole)
Clozaril (clozapine)
Haldol (haloperidol)
Prolixin (fluphenazine)
Risperdal (risperidone)
Other Mood Stabilizers Date Dosage Response/Side-effects
Sedative/Hypnotics Date Dosage Response/Side-Effects
Ambien (zolpidem)
Sonata (zaleplon)
Rozerem (ramelteon)
Restoril (temazepam)
Desyrel (trazodone)
Other Sedative/Hypnotics Date Dosage Response/Side-effects
ADHD medications Date Dosage Response/Side-Effects
Adderall (amphetamine)
Concerta (methylphenidate)
Ritalin (methylphenidate)
Strattera (atomoxetine)
Other ADHD medications Date Dosage Response/Side-effects
Antianxiety medications Date Dosage Response/Side-Effects
Xanax (alprazolam)
Ativan (lorazepam)
Klonopin (clonazepam)
Valium (diazepam)
Tranxene (clorazepate)
Buspar (buspirone)
Other Antianxiety medications Date Dosage Response/Side-effects

Your Exercise Level

Family Psychiatric History

Substance Use

Check if you have ever tried the following

How many caffeinated beverages do you drink a day?

Tobacco History

CURRENT

IN THE PAST

Pipe, cigars, or chewing tobacco

Family Background and Childhood History

Trauma History

Educational History

Occupational History

Relationship History and Current Family

Legal History

Spiritual Life

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