Psychiatric Intake Form
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11Office Location:
15811 Ambaum Blvd. SW Suite 110
Burien, WA 98166
Phone: 206-242-8211
Fax: 206-242-0162
Psychiatric Intake Form
Please complete all information on this form and bring to your first visit, along with any recent lab results. If
you are unable to complete it at home, please come 30-40 minutes prior to your scheduled appointment time
to fill out in the office. You may need to ask family members about the family history. Thank you!
Patient Name_____________________________________________ DOB: ____________ Date:____________
Primary Care Physician________________________________ Phone: ____________ Fax:_________________
Current Therapist____________________________________ Phone:_____________ Fax:__________________
What are the problem(s) you are seeking help for?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
What are your treatment goals?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Suicide Risk Assessment
Have you ever had feelings or thoughts that you didn’t want to live? ( ) Yes ( ) No
Do you currently feel that you don’t want to live?
( ) Yes ( ) No
If YES: On a scale of 1 to 10, (ten being strongest) how strong is your desire to kill yourself currently? _____
Have you ever attempted suicide?
( ) Yes ( ) No
Do you have the means or a plan to kill yourself?
( ) Yes ( )No
Current Symptoms Checklist
Fatigue or loss of energy Decreased interest in activities or excessive guilt Depressed or sad mood
Weight or appetite change Poor concentration Worthlessness Decreased libido Hallucinations
Panic attacks Sleep pattern disturbance Low self-esteem Suspiciousness Low motivation
Excessive energy Excessive worry Irritability Other: _________________________________________
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