Psychological Testing Intake Form "*" indicates required fields Name* First Last Preferred Name:Biological Sex:*Gender Identity:Preferred Gender Pronoun:Date of Birth:* MM slash DD slash YYYY Age:*Please enter a number from 1 to 99.Name of Primary Care Provider (PCP), Phone number:*Name of Psychiatric Care Provider, Phone number:Presenting ProblemWhat brings you in for a psychological assessment? When did you first notice a problem?*Does this problem interfere with everyday activities? If so, how?*Have you ever received treatment for this problem in the past (medications, counseling, psychiatry, other)? If so, when and with whom?*Does anyone in your immediate family have this same or related-problem (who, and when were they diagnosed)?*Please check any of the following that have been problematic over the last 6 (six) months.Tired or Fatigued* NA/Never Rarely Sometimes Often Always Tension or Anxiety* NA/Never Rarely Sometimes Often Always Sleep disturbance* NA/Never Rarely Sometimes Often Always Excessive worry or Nervousness* NA/Never Rarely Sometimes Often Always Anger problems* NA/Never Rarely Sometimes Often Always Feeling hopeless* NA/Never Rarely Sometimes Often Always Depression* NA/Never Rarely Sometimes Often Always Alcohol use problems* NA/Never Rarely Sometimes Often Always Drug use problems* NA/Never Rarely Sometimes Often Always Chronic pain* NA/Never Rarely Sometimes Often Always Memory problems* NA/Never Rarely Sometimes Often Always Attention / Concentration problems* NA/Never Rarely Sometimes Often Always Legal problems* NA/Never Rarely Sometimes Often Always Separation / Divorce* NA/Never Rarely Sometimes Often Always Relationship or Intimacy problems* NA/Never Rarely Sometimes Often Always Problems with children* NA/Never Rarely Sometimes Often Always Low energy or lack of motivation* NA/Never Rarely Sometimes Often Always Work-related problems* NA/Never Rarely Sometimes Often Always Binge or restrictive eating, or eating problems* NA/Never Rarely Sometimes Often Always Irrational fears* NA/Never Rarely Sometimes Often Always Obsessive thoughts* NA/Never Rarely Sometimes Often Always Obsessive actions* NA/Never Rarely Sometimes Often Always Do you hear voices, or see things that aren't there?* NA/Never Rarely Sometimes Often Always Suicidal or homicidal thoughts* NA/Never Rarely Sometimes Often Always Self-harm behavior* NA/Never Rarely Sometimes Often Always Gender identity concerns* NA/Never Rarely Sometimes Often Always Other NA/Never Rarely Sometimes Often Always What:Social HistoryWhat is your current marital status?* Single / dating Married / domestic partner Separated / divorced Widowed / widower How long?Name of your spouse or partner:*How would you describe the quality/satisfaction of your current relationship (if applicable)? Any concerns?*How many children do you have?*BiologicalAdoptedFoster Add RemoveList your children's name, gender, age, marital status, and custody arrangement (if applicable):*Current Residence* Own/Rent home or condo Apartment Other Who lives in the residence with you? Do you have concerns about your living arrangements?*Please list and describe the people in your current support system:*Family of Origin – Who was in your immediate family network (Please list the first name – parents first, then siblings.)?*List family member, gender, age, marital status, occupation, and relationship.Describe your relationship with your parents:*Describe your relationship with your siblings:*Describe your childhood/adolescent years (attitudes, feelings, likes, dislikes, etc.)*Is there a history of verbal, physical, or sexual abuse in your family? If yes, please describe.*Medical and Mental Health HistoryHave you had any major illnesses, chronic conditions, surgeries, injuries, hospitalizations in childhood or adulthood?*List all medications and dosages you are currently taking:*Are you currently, or have you previously received mental health services (therapy, psychological evaluation, psychiatric care)? If yes, please describe and list approximate date(s).*Is there a family history of significant medical or mental health diagnoses? Please explain.*Have you noticed, or has someone else raised concern about your behavior in any of the following? If so, describe: Eating habits, spending/purchasing habits, substance abuse, sleep habits, pornographic use, gambling habits*Substance AbuseAlcohol* Daily Weekly Monthly Past None Amount:Marijuana / Cannabis* Daily Weekly Monthly Past None Amount:Vape / Smoke Nicotine* Daily Weekly Monthly Past None Amount:Barbiturates* Daily Weekly Monthly Past None Amount:Opioids* Daily Weekly Monthly Past None Amount:Stimulants* Daily Weekly Monthly Past None Amount:Hallucinogens* Daily Weekly Monthly Past None Amount:Caffeine* Daily Weekly Monthly Past None Amount:Have you received treatment for any of the above substances? If yes, when, for what substance, and how long?*Do you have any family members with substance abuse problems? If yes, list the relationship and substance abused.*Educational HistoryWhat type of school system did you attend?* Public Private Home school Other Did you receive, or were you enrolled in, special education or supportive services (Behavioral plan, IEP, summer school)? If so, how long did the supports last?*Do you have any certificates, vocational training, or degrees?*Employment HistoryCurrent employer:*How long?*Number of jobs in the last five (5) years?*How would you describe yourself as an employee?What is your career or vocational plan?Legal HistoryNumber of arrests:Number of substance-related arrests:Number of OUIL, DUIL, or DWI infractions or arrests:Nature of other arrests or other legal concerns:*Additional InformationWhat is your cultural, ethnic, or racial identity?Do you have any formal religious affiliation? If so, what is your participation/involvement like?Is there anything else the evaluator should know about you?
