Mental Health IOP Intake Form

Please be as thorough as possible.

"*" indicates required fields

Which Location?*

Name

First Last

Date Of Birth:

Phone:

Email:

Address

Street Address City State ZIP Code

Do you have Insurance?

Yes

No

Primary Insurance:

Primary Insurance ID:*

Do you have Secondary Insurance?

Yes

No

Secondary Insurance:

Secondary Insurance ID:*

Do you currently have any of the following providers?

A Primary Care Doctor?

Yes

No

A Psychiatrist?

Yes

No

A Therapist?

Yes

No

Primary Care Doctor (Full Name):

Doctor Phone Number:

Current Psychiatrist (Full Name):

Psychiatrist Phone Number:

Therapist (Full Name):

Therapist Phone Number:

What are your current diagnosis?*

Are you currently working with any other healthcare providers (e.g. nutritionist, psychiatrist, medical specialists)?*

Yes

No

Please list their name and profession.

Have you ever been hospitalized or received treatment for a Mental Health, Substance Use Disorder, or an Eating Disorder related concern?*

Yes

No

Question Answer: Have you ever been hospitalized or received treatment for a Mental Health, Substance Use Disorder, or an Eating Disorder related concern?*

Are you currently taking medications?*

Yes

No

Are you currently taking medications?

Are you currently experiencing any of the following? :

How much alcohol do you drink on a weekly basis?*

Poor sleep.*

Yes

No

Question Answer: Poor sleep.*

Change in Appetite.*

Yes

No

Question Answer: Change in Appetite.*

Medical Health Problems.*

Yes

No

Question Answer: Medical Health Problems.*

Do you have any history of hallucinations or episodes of psychosis?*

Yes

No

Question Answer: Do you have any history of hallucinations or episodes of psychosis?*

Have you ever been part of an Assertive Community Treatment Team or Wrap around services?*

Yes

No

Question Answer: Have you ever been part of an Assertive Community Treatment Team or Wrap around services?*

Do you abuse or over-use any drugs?*

Yes

No

Question Answer: Do you abuse or over-use any drugs?*

Have you experienced any traumatic events?*

Yes

No

Question Answer: Have you experienced any traumatic events?*

Do you have disordered eating?*

Yes

No

Overall, on a scale of 1 to 5, to what degree are the symptoms you are experiencing affecting your daily life and functioning? (1 being not at all, 5 being severely impacting your daily life)*

Resources and Support :

What activities do you enjoy?

Who is in your current support system?

What are your strengths?

Do you work, go to school, or volunteer?*

Yes

No

Question Answer: Do you work, go to school, or volunteer?

Which location?*

How did you hear about us?

Internet

Social Media

Psychology Today

Word Of Mouth

Medical Provider/Hospital

Other

Which Medical Provider/Hospital?

Other - Please explain:

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