Confidential Intake Forms

Confidential Adult Intake form

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Cell Phone *

(###)

###

####

Occupation

Emergency Contact

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

How where you referred?

Please state briefly what you would like help with or why you were referred:

Please list the names of any current psychotropic medications and what they are prescribed for:

Please list any allergies or medical conditions that I should be aware of:

Please list all family members living in the home, starting with the client.

Check Items that apply to your current and past condition(s):

Drug or Alcohol Abuse

Current

Past

Eating Problems

Current

Past

Sleeping more than normal

Current

Past

Sleeping less than normal

Current

Past

Significant weight change

Current

Past

Life transitions

Current

Past

Loss of appetite

Current

Past

Feeling isolated

Current

Past

Feeling worthless

Current

Past

Restlessness

Current

Past

Suicidal

Current

Past

Suicide attempt(s)

Current

Past

Low energy

Current

Past

Low Motivation

Current

Past

Decreased need to sleep

Current

Past

Excess energy/feeling wired

Current

Past

Mood swings

Current

Past

Confusion

Current

Past

Elated mood

Current

Past

Excessive spending

Current

Past

Racing thoughts

Current

Past

Irritable

Current

Past

Grandiose thoughts/plans

Current

Past

Anger or explosiveness

Current

Past

Thoughts of harming others

Current

Past

Panic Attacks

Current

Past

Worry

Current

Past

Unusual thoughts

Current

Past

Hear things others don’t

Current

Past

See things others don’t

Current

Past

Physical abuse

Current

Past

Sexual abuse

Current

Past

Financial problems

Current

Past

Legal problems

Current

Past

Sexual problems

Current

Past

Health problems

Current

Past

Relationship problems

Current

Past

Divorce

Current

Past

Trauma

Current

Past

Thank you for completing the adult intake form. We will review all of the submitted information when you arrive for your first appointment. We look forward to your visit at Bridges Family Care, have a wonderful day.

Confidential Child, Adolescent & Family Intake Form

Child/Teen's name *

First Name

Last Name

Nickname

DOB *

MM

DD

YYYY

Age *

Sex *

Ethnicity/country of origin

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Full time student

Yes

No

Grade

Name of adult completing this form: *

First Name

Last Name

Relationship

Legal Guardian

Yes

No

Phone

(###)

###

####

Email

Okay to send email?

Yes

No

Okay to leave voicemail?

Yes

No

Okay to send text messages?

Yes

No

Mother's Name

First Name

Last Name

Mother's Phone

(###)

###

####

Father's Name

First Name

Last Name

Father's Phone

(###)

###

####

Marital Status

Married

Divorced

Separated

Unmarried

If divorced, who has legal custody?

If divorced, what year was it finalized?

Guardian's Name (if applicable)

First Name

Last Name

Guardian's Phone

(###)

###

####

School Name

School Counselor

Pediatrician

Pediatrician Phone

(###)

###

####

Child's main problem/major reason for seeking help now

Describe any other behavioral or emotional problems

Describe the impact of your child's problems on the family

Describe your child's strengths and unique qualities

Describe your family strengths and support

Child's previous treatment(s)

None

Individual Therapy

Family Therapy

Inpatient

Residential

Psychiatry Medication

If any treatment(s), please specify focus and providers

Individuals who currently live with the child

List any problems with pregnancy, labor, or delivery

For the following, please check all that apply

Child's Exposure during pregnancy

None

Alcohol

Drugs

Tobacco

Accident

Illness

Delays in developmental milestones

None

Talking

Walking

Toilet Training

Other

If other, please specify

Medical problems

Allergies

Asthma

Head Injury

Operation(s)

Poisoning

Serious Infection

Convulsions

Bladder/Bowel

Other

If other, please specify

Social skills with peers

Poor

Average

Good Unknown

Behavior with Sibling(s)

Poor

Average

Good

N/A

Behavior with caregiver(s)

Poor

Average

Good

N/A

Average hours of exercise per day

Average hours of 'screen time' per day

Average hours of sleep per night

Child Abuse

None

Physical

Sexual

Emotional

Neglect

Pending legal action

Option One

Option Two

Juvenile justice involvement

Option One

Option Two

Firearms in the home

Option One

Option Two

If yes, are the firearms secured?

Option One

Option Two

Educational History

Proficiency testing:

Poor

Average

Above Average

Unknown

Academic Services (check all that apply)

Home Study

Independent Study

Continuation School

Gifted Program

Speech Therapy

Resource Classes

Individualized Education Plan

Learning Difficulties

Poor Grades

Frequent Discipline

Suspension / Expulsion

Other

If other, please list

Child's biological family history of mental health condition(s)

Depression, anxiety, ADHD, addition, etc...

Child/teen's current or past problems

Self Injury

Suicidal thoughts

Homicidal thoughts

Alcohol

Drug use

Exposure to traumatic event

Hearing/seeing things that others do not

Tics

Repetitive behaviors

List any past/current established mental health diagnosis

Thank you for completing the minor intake form. We will review all of the submitted information when you arrive for your first appointment. We look forward to your visit at Bridges Family Care, have a wonderful day.

Bridges Family Care Inc., 6101 Bollinger Canyon Road Suite 311, San Ramon, CA, 94583, United States844-377-2942razia.iqbal@bridgesfamilycare.com

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