Psychiatric Intake Form (Page 5 of 11) in pdf

Social History

Family Background

List your siblings/ ages:

_________________________________________________________________________________ Were you

adopted? Yes( )No( )

Did your parents divorce? Yes ( ) No ( ) How old were you when they divorced? ________________________

Has anyone in your immediate family died? Yes ( ) No ( ) Who and when?

____________________________________ Trauma History

Do you have a history of being abused emotionally, sexually, physically, or by neglect? Yes ( ) No ( )

Other trauma history:

__________________________________________________________________________________ Education/ Work

History

What is your highest level of education?

___________________________________________________________________ Are you currently: Working ( ) Not

working by choice ( ) Unemployed ( ) Disabled ( ) Retired ( )

What is/ was your occupation?

___________________________________________________________________________ Have you ever served in

the military? Yes ( ) No ( ) Were you in combat? Yes ( ) No ( )

Relationship History

Are you currently: Married ( ) Single ( ) Divorced ( ) Widowed ( ) Partnered ( ) Other relationship ( )

Are you sexually active? Yes ( ) No ( )

Describe your relationship with your partner:

_______________________________________________________________ Do you feel safe in your current

relationship? _______________________________________________________________ Do you have children?

List ages/ gender ___________________________________________________________________ Legal History

Have you ever been arrested? Yes ( ) No ( ) Do you have any pending legal problems? Yes ( ) No ( ) Spiritual

Life

Do you belong to a particular religion or spiritual group? Yes ( ) No ( )

If yes, what is the level of your involvement?

________________________________________________________________ Do you find your spiritual involvement

helpful during this difficult time, or does the involvement make things more difficult or stressful for you?

______________________________________________________________________________________

Is there anything else that you would like your psychiatric provider to know?

__________________________________________________________________________________________________

Psychiatric Intake Form Page 5