EBHS Individual Intake Form - Effect Behavioral Health Solutions Inc.

Is the client over the age of 18. *

Name of Client *

First

Last

Date of Birth *

Ex, 10/09/1990

Social Security Number *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Insurance Type

main things or

Insurance Member Number

Please explain why you came to therapy. *

What symptoms are you presenting *

How long have you been dealing with the problem? *

Have you ever ben diagnosed with a mental health condition? *

Please share all diagnoses and date of these diagnoses. *

If none please put N/A

Do you have any medical conditions; if so please describe. *

IF none, put N/A

Do you take any prescription medications? *

If you take any prescription medication, please list below. *

Please include mental health and medical prescriptions. If none put N/A.

Has anyone in your family ever been diagnosed by a provider with a mental health condition? If yes, please list the family(s) relationship and diagnosis. *

If no put N/A.

Do you have any past mental health or psychiatric hospitalizations? If so, please list the number if times, name of the hospital(s) and date(s). *

If no put N/A.

Have you been counseling previously? If so shared the when, why, where, how long, and the outcome. *

If no put N/A.

• Have you experienced any major losses, trauma, or stressful life events? *

If no put N/A.

Do you have a history of drug use or alcohol use? If so please list substances used and for how long. Also list if you currently use. *

If no put N/A.

What trauma have you experienced please explain. *

If no put N/A.

Have you ever attempted suicide? *

If you have attempted suicide, please explain dates, method, and reasoning. *

If no put N/A.

• Have you experienced anxiety, depression, mood swings, or panic in the past? *

Yes
No

Please describe the relationship with your family members. If the person is deceased, please list the relationship before passing. Use following below: Close: You can share anything with them, and you have a strong bond and trust. Friendly: You have a good relationship; you can tell them some things but not all things. Distant: You have no relationship and have not talked to them in a month or longer. Conflict: You have an ongoing conflict with this person or have been in recent conflict and find it hard to speak with them. *

• What made you decide to start therapy at this time? *

• What are the main concerns or challenges you’re currently facing? *

• When did these issues begin and how have you coped?

• How do you usually cope when you’re feeling overwhelmed? *

• What are some strengths you have that you may not give yourself credit for? *

List some things you feel you to improve on? *

• How would you describe your relationships with family or close friends? *

• Are there any relationship conflicts impacting your mental health? *

• Are there specific goals you’d like us to work toward together? *