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contact@ewingmentalhealthllc.com

Ewing Mental Health LLC

INTAKE FORM

Intake Form

Fill and submit the form below with the correct information.

Enter Name Here
Marital Status
Gender
DOES ANYONE ELSE LIVE IN THE SAME HOME WITH YOU?

PAST PSYCHIATRIC HISTORY

PLEASE LIST ANY OTHER PERSON WHO HAS BEEN PROVIDING OR HAS PROVIDED MENTAL HEALTH CARE FOR YOU AND WHEN YOU WERE UNDER THEIR CARE. THIS MAY BE ANOTHER PSYCHIATRIST, A PSYCHOLOGIST, SOCIAL WORKER, SCHOOL COUNSELOR, INDIVIDUAL THERAPIST, MARITAL THERAPIST, MINISTER, PRIEST OR PASTORAL COUNSELOR. YOU SHOULD INCLUDE ANYONE WHO HAS PRESCRIBED PSYCHIATRIC MEDICATION FOR YOU (PRIMARY CARE PROVIDER, OBGYN, FAMILY NURSE PRACTITIONER, OTHER HEALTH CARE PROVIDER.
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LIST ALL CURRENT MEDICATIONS, DOSAGE, INSTRUCTIONS, WHO PRESCRIBES THEM AND WHAT YOU TAKE THEM FOR:


HAVE YOU EVER ATTEMPTED SUICIDE?
HAVE YOU EVER BEEN PSYCHIATRICLY HOSPITALIZED?
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ALCOHOL AND DRUG HISTORY

ALCOHOL USE
Untitled
Alcohol
MARIJUANA
COCAINE
CRYSTAL METH
ICE
ADDERALL
VYVANSE
RITALIN
LSD
XTC/MOLLY
PEYOTE
KETAMINE
MUSHROOMS
XANAX
VALIUM
KLONOPIN
ATIVAN
DEXTROMETHORPHAN
STEROIDS
SPICE
BATH SALTS

PLEASE LIST PLACES WHERE YOU HAVE BEEN TREATED FOR ALCOHOL OR DRUG-RELATED PROBLEMS BELOW:

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TREATMENT
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TREATMENT
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TREATMENT
HAVE YOU EVER PARTICIPATED IN 12-STEP RECOVERY (AA/NA)?
DO YOU CURRENTLY PARTICIPATE IN 12-STEP RECOVERY?

PAST MEDICAL HISTORY

PAST SURGICAL HISTORY

FAMILY HISTORY

PSYCHOSOCIAL HISTORY

DID ANYONE EVER PHYSICALLY ABUSE YOU?
DID ANYONE EVER EMOTIONALLY ABUSE YOU?
DID ANYONE EVER SEXUALLY ABUSE YOU?
WHAT IS YOUR HIGHEST LEVEL OF EDUCATION?
ARE YOU EMPLOYED?
DID YOU EVER WORK?
ARE YOU MEDICALLY DISABLED?
WHAT IS YOUR SEXUAL PREFERENCE?
ARE YOU CURRENTLY INVOLVED IN A LAWSUIT?