Intake Questionnaire LMA

LMA Mental Health Services LLC

Intake Questionnaire

This questionnaire is designed to determine if telehealth is the appropriate level of care for you

Please answer those questions as best you can

All fields are required

Thank you in advance

New Patient Intake Form

Background Information

Date

First Name

Last Name

Street address

City

State (you must live in Florida)

Zip Code

Phone/ Mobile

Date of Birth

Age (in years)

Biological Sex

Male

Female

Gender Identity

Male

Female

Male to Female (MTF/Transgender Female/Trans Woman)

Female to Male (FTM/Transgender Male/Trans Man)

Genderqueer, neither exclusively female nor male

Choose not to disclose

Other

Sexual Orientation

Asexual

Bisexual

Heterosexual, straight

Homosexual, gay, lesbian

Something else

Don’t know

Choose not to disclose

Family Background and Childhood History

Were you adopted?

Yes

Elaborate in details

Where did you grow up?

Your father

Living

Deceased

Your father’s age, occupation, etc.

Year of his death, age

How old were you when this occurred?

Your mother

Living

Deceased

Your mother’s age, occupation, etc.

Year of her death, age

How old were you when this occurred?

Describe your mother/ father and your relationship with them

How old were you when you left home?

Did your parents’ divorce?

Yes

How old were you when they divorced? Whom did you live with after their divorce?

Has anyone in your immediate family (except your father/ mother) died?

Yes

Who, when, and cause of death?

Do you have any siblings?

Yes

Names, genders, and YEAR of BIRTH of your siblings. What is your birth order out of how many?

Trauma History

Do you have a history of being abused emotionally, verbally, sexually, physically or by neglect?

Yes

Elaborate (when, where, by whom, treatment received, etc.)

Educational History

Did you complete the high school program?

Yes

Highest grade completed? Where? When?

Do you have a GED or state equivalency?

Yes

Did you attend college?

Yes

Name of the school, highest educational degree, field, year of graduation; if dropped out, how long did you study? Reason for dropping out, etc.

Why not?

Occupational History

Are you currently

Working

Student

Unemployed

Disabled

Retired

Other

Who is your employer/ company’s name? What is your occupation? How long have you been in your present position?

Student

Full-time

Part-time

What is the field and level (undergraduate/ graduate) of your studies?

Since when you are unemployed? What is the reason for your unemployment? What was your occupation?

Since when you are disabled? Type of disability? Describe in details

When did you retire? What was your occupation before retirement? Describe in details

Describe in details

Have you ever served in the military?

What branch, when, how long?

Honorable discharge

Type of discharge

Relationship History and Current Family

You are:

Married

Single

Partnered

Divorced

Widowed

What year did you get married? What is your spouse/significant other’s occupation? Please describe your relationship with your spouse/significant other.

How long have you been together? What is your partner’s/significant other’s occupation? Please describe your relationship with your partner/significant other

When did you get divorced? What was the reason for the divorce? How long were you married before?

Since when have you been widowed? What was the length of your prior marriage (or marriages)?

Is this your first marriage?

Yes

Was this your first marriage?

Yes

Are you currently in a relationship?

Yes

Please provide details about your previous marriages, including the year of marriage/divorce, reasons for marriage/divorce, and any additional relevant information

Describe the history of your previous marriage/marriages, including the year of marriage/divorce, reasons, etc.

Describe your current relationships

Are you currently in a relationship? If so, please describe it.

Do you have children?

Yes

How many? List of children names, genders, and year of birth. Describe your relationships with your children, etc.

Do you live alone?

Yes

Elaborate (renting or owing property, list EVERYONE who currently lives with you, relationships with you, etc.)

Are you sexually active?

Yes

Are you pregnant?

Yes

When are you expecting?

Are you nursing?

Yes

When did you start and plan to finish?

Legal History

Have you ever been arrested?

Yes

Describe in details, including the year, reason, and outcome

Do you have any pending legal problems?

Yes

Describe in details, including the year, reason, and current status

Spiritual Life

Do you belong to a particular religion or spiritual group?

Yes

What is the level of your involvement? Do you find your involvement helpful during this illness, or does the involvement make things more difficult or stressful for you?

Exercise Level

Do you exercise regularly?

Yes

How many days a week do you get exercise? How much time each day do you exercise? What kind of exercise do you do?

Why not?

In case of emergency

Telehealth services

There are additional procedures that we need to have in place specific to the Telehealth services. These are for your safety in case of an emergency and are as follows:

– You understand that if you are having suicidal or homicidal thoughts, experiencing psychotic symptoms, or in a crisis that we cannot solve remotely, your provider may determine that the Telehealth services are inappropriate and you need a higher level of care,

– An Emergency Contact Person (ECP) may only be contacted on your behalf in a life-threatening emergency,

– Please enter this person’s name and contact information below,

– You should verify that your ECP is willing and able to go to your location in an emergency. Additionally, if you, your ECP, or your provider determine, if necessary, the ECP agrees to take you to a hospital,

– Your ECP will be contacted only in the extreme circumstances stated above.

Emergency contact person’s full name

Phone/ Mobile

Street address

City

State

Zip Code

Relationship of emergency contact person to you

Describe in details

Personal & Family Medical History

Do you have any allergies?

Medication

Food

Environmental

Other

None

Describe in details

Your current weight (lbs)

Your current height (feet and inches)

Your current height (in inches)

How many hours of sleep do you get on most nights of the week?

Do you feel completely rested next morning?

Yes

Elaborate in details

Do you take any prescription medications (NON-PSYCHIATRIC)?

Yes

List ALL PRESCRIPTION medications (NON-PSYCHIATRIC), dosage, times per day, reason and duration of treatment

Do you take any over-the-counter medications or supplements regularly?

Yes

List all over-the-counter medications/ supplements you take regularly; reason of taking, dose, frequency, how long taking the OTC meds

Do you have a history of medical problems, NON-PSYCHIATRIC hospitalization, or surgeries in the PAST?

Yes

List of the facility names, dates (year), length of stay, the reason for hospitalization, outcome, etc.

Primary Care Provider’s (PCP) full name

Office address/ phone number of your Primary Care Provider (PCP)

Have YOU or ANYONE in your direct family been diagnosed with any of those diseases?

Thyroid disease (hyperthyroidism (Graves disease) or hypothyroidism)

Diabetes (type I or type II)

Anemia (including Pernicious anemia)

Liver disease/ Hepatitis

Kidney disease

Stomach/ intestinal problems

Asthma/ COPD/ respiratory problems

Heart Disease/ High Cholesterol/ Heart attacks

Angina/ chest pain

Epilepsy/ seizures

Head trauma

Fibromyalgia

Chronic Pain

Arthritis (Rheumatoid, Reactive, etc.)

Cystic Fibrosis

Hormone-related problems

Cancer

HIV/ AIDS

Addison disease

Celiac disease – sprue (gluten-sensitive enteropathy)

Dermatomyositis

Multiple sclerosis

Sjögren’s syndrome

Systemic Lupus Erythematosus (SLE)

None

Elaborate in detail (you or someone in your direct family, when they had been diagnosed with the condition, the treatment prescribed, the outcome, etc.)

Is there any additional personal or family medical history?

Yes

Please provide additional details regarding any family medical history

When your mother was pregnant with you, were there any complications during the pregnancy or birth?

Yes

Please provide detailed information about any complications that occurred during your mother’s pregnancy or during your birth

Personal Mental Health History

History of any outpatient treatment for your mental health issues

Yes

Please provide a detailed description of your history with outpatient treatment for your mental health issues

History of PSYCHIATRIC hospitalization

Yes

List of PSYCHIATRIC hospitalizations in details, including facility name, date (year), length of stay, the reason for hospitalization, outcome, etc.

Did you take any prescribed PSYCHIATRIC medications in the PAST?

Yes

Did you take the following:

Antidepressants

Mood stabilizers

Antipsychotics

Sedatives

ADHD medications

Antianxiety medications

Other

Which ones?

Prozac (fluoxetine)

Zoloft (sertraline)

Luvox (fluvoxamine)

Paxil (paroxetine)

Celexa (citalopram)

Lexapro (escitalopram)

Effexor (venlafaxine)

Pristiq (desvenlafaxine)

Cymbalta (duloxetine)

Wellbutrin (bupropion)

Remeron (mirtazapine)

Serzone (nefazodone)

Anafranil (clomipramine)

Pamelor (nortrptyline)

Tofranil (imipramine)

Elavil (amitriptyline)

Other

Which ones?

Lithium

Depakote (valproate)

Lamictal (lamotrigine)

Tegretol (carbamazepine)

Topamax (topiramate)

Other

Which ones?

Seroquel (quetiapine)

Zyprexa (olanzepine)

Abilify (aripiprazole)

Risperdal (risperidone)

Clozaril (clozapine)

Haldol (haloperidol)

Prolixin (fluphenazine)

Other

Which ones?

Ambien (zolpidem)

Sonata (zaleplon)

Lunesta (eszopiclone)

Rozerem (ramelteon)

Restoril (temazepam)

Desyrel (trazodone)

Other

Which ones?

Adderall (amphetamine)

Vyvanse (lisdexamfetamine)

Ritalin (methylphenidate)

Concerta (methylphenidate)

Strattera (atomoxetine)

Other

Which ones?

Xanax (alprazolam)

Ativan (lorazepam)

Klonopin (clonazepam)

Valium (diazepam)

Tranxene (clorazepate)

Buspar (buspirone)

Inderal (propranolol)

Other

Which ones?

Other

Describe in details, including the dosage, frequency, reason for the treatment, duration of the treatment, outcome, any side effects experienced, and the reason for discontinuation, etc.

Are you CURRENTLY prescribed any psychiatric medications?

Yes

List of CURRENT medication, including the name of medication, dose/ frequency, reason and duration of treatment, efficacy of medication, side effects, etc.

Are you CURRENTLY receiving psychotherapy/ therapy?

Yes

Who is your current psychotherapist? Therapist’s address/ phone number?

Family Psychiatric History

Has ANYONE in your family been DIAGNOSED with the following:

Bipolar disorder

Depression

Anxiety

Anger issues

Schizophrenia

Alcohol use disorder

Substance use disorder

Autism spectrum disorder (ASD)

Asperger’s syndrome

Developmental disorders

Speech disorders

Post-traumatic stress (PTSD)

Violence

Other

None

Elaborate in details (who and when had been Diagnosed)

Has any family member been TREATED with a psychiatric medication?

Yes

Please provide detailed information (including who, when, how many times, reasons for treatment, medications prescribed, etc.) about any family member who has received treatment with psychiatric medication

Has any family member died by suicide?

Yes

Please provide comprehensive details regarding this

Substance Use

Have you ever been treated for alcohol or drug use or abuse?

Yes

For which substances? Describe in details including where, when, how long did you receive treatment, etc.

Substance Use – Alcohol

Do you drink alcohol?

Yes

How many days per week do you drink any alcohol?

What is the least number of drinks you will drink in a day?

What is the highest number of drinks you consume in a day? How frequently does it occur? When was the last time it happened?

In the past THREE months, what is the largest amount of alcoholic drinks you have consumed in one day?

CAGE-AID

Have you ever felt you ought to cut down on your drinking or drug use?

Yes

Have people annoyed you by criticizing your drinking or drug use?

Yes

Have you ever felt bad or guilty about your drinking or drug use?

Yes

Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?

Yes

Do you think you may have a problem with alcohol use?

Yes

Illicit substances

In the past THREE months, have you used any street drugs?

Yes

Which ones?

Marijuana

Methamphetamine

Cocaine

Stimulants (pills)

Heroin

Pain killers (pills)

Methadone

Tranquilizer (Sleeping pills)

LSD Hallucinogens

Ecstasy

Other

Please provide a detailed description, including the amount of illicit substances you have used in the past three months, their frequency, duration, and any other relevant information

Have you ever abused/ misused prescription medication?

Yes

Please provide detailed information, including the name of the medication, dosage, frequency, duration, outcomes, etc.

Do you think you may have a problem with drug use?

Yes

Describe in detail why you believe you may have a problem with drug use?

Caffeine

Do you regularly drink caffeinated beverages, such as coffee, energy drinks, pre-workout, sodas, etc.?

Yes

Explain (number of cups or cans (8oz)) a day, names of energy drinks, pre-workout, sodas, amount (in mg) of caffeine per day, etc.)

Smoking

Do you (or have you ever) smoke cigarettes?

Yes (currently smoke)

Yes (historical smoking)

How many packs per day on average? How many years?

When did you quit smoking?

Do you (or have you ever) smoke pipe, cigars, or chewing tobacco?

Yes (currently use)

Yes (historical use)

What kind? How often per day on average? How many years?

When did you quit?

Current Mental Health Status

Are you CURRENTLY or in the last 30 days experienced any of the following symptoms?

Anxiety (regular, fluctuating, etc.)

Anger (increased intensity)

Appetite/ sleep changes

Can’t be in crowds

Can’t concentrate

Depressed/ sad

Fatigued/ no energy

Fearfulness (increased intensity)

Grief & Loss

Guilt/ Helplessness/ hopelessness

Hearing things/ seeing things that are not there

Increased Energy (increased intensity)

Impulsiveness

Insomnia/ Difficulty falling/ staying asleep

Lack of interest/ motivation

Panic attacks

Paranoia

Poor memory

Prefer to be alone

Restlessness

Reoccurring nightmares

Self-esteem problems

Self-harm

Suspiciousness/ People out to get you

Suicidal thoughts

Other

None

Describe in details

What concerns would you like to discuss with the Psychiatric Mental Health provider?

ADHD

Anxiety

Depression

Insomnia

Other

Elaborate in details

How long have you had those concerns?

Up to two weeks

2 weeks – 2 months

2 months – 1 year

1 year – 2 years

More than two years

Are you currently going through any of the following situations?

Life event/ transition/ increased stress

Family/ relationship challenges

School/ career challenges

Medical conditions

Loss of a loved one

Pregnancy/ breastfeeding

Other

Elaborate in details

How much are your concerns affecting your ability to enjoy daily activities/ relationships with family and friends?

Not at all

Very little

Somewhat

A good amount

A lot

Over the past few weeks, how often have you been bothered by feeling down, depressed, or hopeless?

Not at all

Several days

More than half of days

Nearly every day

Do any of the following apply to you in the past three months?

Smoked/ used marijuana products

Smoked/ used CBD products

Regularly used recreational drugs (not marijuana or CBD)

Drank more than 15 drinks/week

None

Describe in details

What are your treatment goals?

Other

Is there anything else that you would like us to know?

Whom may we thank for referring you?

Primary Care Provider

Family member or friend

Internet website

Other

None

Full name

Which one?

Elaborate

Payment Options

Which one do you want to use?

Insurance

Cash, out-of-pocket

Insurance title

Member ID/ Group number

Suicide Risk Assessment

Have you ever experienced feelings or thoughts of not wanting to live?

Yes

Was it more than five years ago?

Yes

When did the episode happen last? Please provide a detailed explanation

Are you currently experiencing, or have you experienced within the past six months, a feeling of not wanting to live?

Yes

How often do you have these thoughts?

When was the last time you had thoughts of dying?

Has anything happened recently to make you feel this way?

On a scale of 1 to 10 (ten being strongest), how strong is your desire to kill yourself currently?

Would anything make it better?

Have you ever thought about how you would kill yourself?

Is the method you would use readily available?

Have you planned a time for this?

Is there anything that would stop you from killing yourself?

Do you feel hopeless and/ or worthless?

Have you ever tried to kill or harm yourself before?

Do you have access to guns? Please explain

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