Monica King LMSW ACSW
                         2227 Packard, #2	
____________________	Ann Arbor, Michigan	___________	
Date		Case #	
	ADULT INTAKE INFORMATION	
____________________________________________________________	_________________________	
Name	Home Phone	Business Phone	
____________________________	___________________________________	
Cell phone/other phone	Email		

____________________________________________________________________________________________________

Street Address		City	State	Zip Code	
________________	_______________	Marital Status:	Single     Married    Divorced		
Date of Birth	Sex	   (circle)	Widowed      Living with partner		
____________	_________________________	___________________________________		
Age	SSN		Driver’s License #		

Referred by:____________________________________________

In Case of emergency, contact (Name, relationship and phone number):

PLEASE CIRCLE FORM OF PAYMENT:	CASH		INSURANCE		
________________________	_____________________________	____________________	___________________	
Primary Insurance	Policyholder’s Name		Relationship	Policyholder DOB	
________________________	_______________	___________________________________	______________________	
Contract Number	Group Number		Policyholder’s Employer	Policyholder SSN	
________________________	_____________________________	____________________	____________________	
Secondary Insurance	Policyholder’s Name		Relationship	Policyholder DOB	
________________________	_______________	__________________________________	_____________________	
Contract Number	Group Number		Policyholder’s Employer	Policyholder SSN	

It is important to us to be responsive to our patients’ needs and your feedback is very useful to us. Please rate the timeliness of scheduling your first appointment:

	Excellent	Good	Fair	Poor	Very Poor		
5	4	3	2	1			

________________________________________________________	_________________________		
	**DSM-IV				Code				
________________________________________________________	_________________________		
	Therapist Signature				Therapist Code		
	Print Name:______________________________________________					
									
	Insurance	Deductible		Copay	Yearly maximum		Lifetime max		
	Primary								
	Secondary								

If applicable:

Authorization #:____________________________Number of sessions:________Dates covered:____________________________

Rev. 8/07

1

What are your reasons for seeking treatment at this time?

Have you seen a mental health or substance abuse professional (psychiatrist, psychologist, or social worker) in the past? If yes, explain.

Have you ever taken medications for a mental health, emotional problem, or substance abuse problem?  If yes, explain.

_____________________________________________________________________________________

Have you attended any self-help groups?  If so, explain.

Family Information

Spouse’s name	Spouse’s Date of Birth	Spouse’s Occupation

Children’s Name(s), age(s), sex.  Specify if child lives at home.  Previous marriage(s) and children.

_____________________________________________________________________________________
List significant extended family members.  (Parent, brothers and sisters, etc.)

Explain any family history of physical illness or significant hospitalizations.

_____________________________________________________________________________________
Explain any family history of mental or emotional illnesses, psychiatric hospitalization, history of suicide.

_____________________________________________________________________________________
Any family history of substance abuse?  Who was that?  What substance(s) was abused?

_____________________________________________________________________________________
Please describe any spiritual/religious/cultural affiliations.

_____________________________________________________________________________________
Are social supports adequate at present?  (Family, friends, co-workers)

_____________________________________________________________________________________

Occupational/Educational History

Current employer and your job title

____________________________________________________________________________________

General satisfaction with your job

____________________________________________________________________________________

List past jobs and any comments:

____________________________________________________________________________________

2

Are you satisfied with your overall financial status?  If not, explain.

____________________________________________________________________________________
Highest grade completed:

____________________________________________________________________________________
Describe your school performance:

____________________________________________________________________________________
Do you have any future plans for education?  If yes, describe.

____________________________________________________________________________________
Leisure Activities

____________________________________________________________________________________
List some of your hobbies, activities, and talents.

____________________________________________________________________________________

With whom do you spend most of your free time?

____________________________________________________________________________________

Medical History
____________________________________________________________________________________

Name and address of your primary care physician

____________________________________________________________________________________

Height:_________________  Weight:____________________

____________________________________________________________________________________
When was your last physical exam?

____________________________________________________________________________________
Do you have any allergies?  If yes, explain.

____________________________________________________________________________________
List all prescribed medications you are taking.  Include dosage and frequency.

____________________________________________________________________________________

List all over-the-counter (including vitamins, minerals, diet pills, supplements, herbs, and other “natural” remedies) you are taking.

____________________________________________________________________________________

Have you ever had a problem with overuse of prescribed medications?  If yes, explain.

____________________________________________________________________________________
Describe any surgeries, serious accidents, or hospital admissions.

_____________________________________________________________________________________

Indicate whether you have had any of the following illnesses/symptoms.

	Now		Ever			Now		Ever		
	Yes	No	Yes	No		Yes	No	Yes	No	
Anemia					High blood pressure					
Arthritis					Immune problems					
Asthma					Kidney disease					
Cancer					Paralysis					

3

	Now		Ever			Now		Ever		
	Yes	No	Yes	No		Yes	No	Yes	No	
Diabetes					Prostate problems					
Earaches, infections					Seizures, epilepsy					
Emphysema					STDs					
Fainting/dizziness					Sleep problems					
Excessive fatigue					Stroke					
Headaches					Thyroid disease					
Head injury					Ulcers (GI)					
Heart problems					Urinary infections					
Hepatitis					Vision/hearing problems					
Other:					Other:					
Do you have physical pain?  Yes_____No_____
If yes, rate the intensity of the pain:  1(mild) to 5 (severe): ____________.

If yes, where is the pain located: _________________________________________________. If yes, how does it impact your functioning?

_____________________________________________________________________________________

Do you drink coffee, tea, cola, or consume other food, beverages, or medicines with caffeine? If so, please describe how much per day?

_____________________________________________________________________________________
Please provide information on your use of non-medical drugs.

Substance	Used within 48 hrs.?	How often used?	Year first used?	When last used?	
Cigarettes/tobacco								
Alcohol								
Sleeping pills								
Marijuana								
Inhalants								
Cocaine/crack								
Heroin								
Other:								
Military History								
Branch		Rank		Time in service	Active combat	
								
Legal History
_____________________________________________________________________________________
Do you have any pending or prior legal problems?  If yes, explain.

_____________________________________________________________________________________

Other:
Is there anything else you think we ought to know about you or you would like to tell us?

_____________________________________________________________________________________

Patient Signature:_______________________________________Date:_________________________

For therapist use only:

If it has been over a year since the patient’s last physical, did you suggest that he/she have a physical? Yes_____No_____ Did the patient agree to this? Yes_____ No_____

Therapist/MD signature:_____________________________________Date:_______________________

4

ADULT SYMPTOM CHECKLIST

NAME:____________________________ AGE:______________ DATE:______________________
__________________________________________________________________________________________

Please circle the symptoms that apply to you now in the past few weeks:

Never  Rarely	Sometimes		Always	
Depression	0	1	2	3	4	5	
Crying spells	0	1	2	3	4	5	
Hopelessness	0	1	2	3	4	5	
Worthlessness	0	1	2	3	4	5	
Sleep disturbance	0	1	2	3	4	5	
Trouble falling asleep	0	1	2	3	4	5	
Interrupted sleep	0	1	2	3	4	5	
Early morning wakening	0	1	2	3	4	5	
Oversleeping	0	1	2	3	4	5	
Loss of appetite	0	1	2	3	4	5	
Overeating	0	1	2	3	4	5	
Weight loss or gain	0	1	2	3	4	5	
If so, how much in the last 3-6 months:						
Gained:_____Lost:______							
Lack of interest in usual things	0	1	2	3	4	5	
Suicidal thoughts, present	0	1	2	3	4	5	
Suicidal thoughts, past	Yes_____No_____	
Suicide attempt, gesture	Yes_____No_____	
Homicidal thoughts	0	1	2	3	4	5	
Anxiety, nervousness	0	1	2	3	4	5	
Irritability, edginess	0	1	2	3	4	5	
Mood swings	0	1	2	3	4	5	
Racing thoughts	0	1	2	3	4	5	
Hard to concentrate/	0	1	2	3	4	5	
stay focused on task							
Fatigue/tiredness	0	1	2	3	4	5	
Bursts of energy	0	1	2	3	4	5	
Worry	0	1	2	3	4	5	
Fears of ordinary things	0	1	2	3	4	5	
(for example, crowds, germs, doctors, flying, closed spaces)

Yelling/screaming	0	1	2	3	4	5	

On the go, hard to relax	0	1	2	3	4	5	
Periodic overspending	0	1	2	3	4	5	
Gambling problem	0	1	2	3	4	5	
Alcohol problem	0	1	2	3	4	5	
(in the last year)							
Drug problem	0	1	2	3	4	5	
(in the last year)							
Blackouts, shakes, tremors	0	1	2	3	4	5	
Anxiety/panic attacks	0	1	2	3	4	5	
Heart beating fast	0	1	2	3	4	5	
Chest pains/tightness	0	1	2	3	4	5	
Lightheadedness	0	1	2	3	4	5	
Stomach upset	0	1	2	3	4	5	
Sexual difficulties	0	1	2	3	4	5	
Relationship problems	0	1	2	3	4	5	
Work problems	0	1	2	3	4	5	
Eating disorder	0	1	2	3	4	5	
Suspiciousness/paranoia	0	1	2	3	4	5	
Feeling controlled	0	1	2	3	4	5	
Hitting/domestic violence	0	1	2	3	4	5	
Hearing voices	0	1	2	3	4	5	
(that others don’t)							
Seeing things	0	1	2	3	4	5	
(that others don’t)							
Need for cleanliness	0	1	2	3	4	5	
Need for organization	0	1	2	3	4	5	
Counting behavior/thoughts	0	1	2	3	4	5	
Rituals that you must do/	0	1	2	3	4	5	
need to check and recheck							
Unexplained physical symptoms 0	1	2	3	4	5	
Trauma, other abuse	0	1	2	3	4	5