Adult Intake Form

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e.g. type in Mar 3 2011

Your Information
Partner's Information
Physical Health Information

Please list all medications that you presently take

Medication What is it Used For? Dosage
Family History

Have any of your biological relatives on either side of the family had any of the following:

Condition or Event Relationship to Yourself
Anxiety
Panic Attacks
Depression
Obsessive-compulsive disorder
Bipolar disorder
Death from suicide
Alcohol or drug problems
Police record (arrests, jail)
Schizophrenia
Developmental delays
Autism/ Asperger's
Learning disorder
Attention problems (ADHD)
Tourette's or other tic problems
Other (please describe)
Family Information

Children

Name Age

Step Children

Name Age
General Review
What are your top three concerns?
Name of Professional Agency Date of Service