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It may seem long, but most of the questions require only a check, so it will go quickly. You may need to ask family members about the family history. Thank you.  \nName:   Date of Birth:   Gender:   Primary Care Physician (PCP):   PCP Phone:    \nAre you receiving mental health treatment at this time? 􀂅 Yes 􀂅 No If YES, where:    \n\n| What mental health services are you seeking?\u003Cbr>􀂅 Psychiatry 􀂅 Therapy/counseling Why are you seeking mental health treatment at this time?\u003Cbr>1.   2.  \u003Cbr>3.   What do you hope to gain from mental health treatment? What would you like to be different?\u003Cbr>1.   2.   3.  \u003Cbr>What do you like about yourself? What are your personal strengths?   |\n| --- |\n| What are your interests and hobbies?   |\n| What is important to you?   |\n\nWhat helps you to feel calm?    \nCurrent Symptoms Checklist: (check for any symptoms present, twice for major symptoms)  \n􀂅 Depressed Mood  \n􀂅 Unable to enjoy activities  \n􀂅 Increased need for sleep  \n􀂅 Decreased need for sleep  \n􀂅 Loss of interest  \n􀂅 Decrease in energy  \n􀂅 Concentration/ forgetfulness  \n􀂅 Change in appetite  \n1  \nEffective 1/03/17  \nPlease Check All Symptoms That Apply  \n􀂅 Excessive guilt  \n􀂅 Fatigue  \n􀂅 Decreased libido  \n􀂅 Increased libido  \n􀂅 Racing thoughts  \n􀂅 Impulsivity  \n􀂅 Risky behavior (explain,  \n  )  \n􀂅 Excessive energy  \n􀂅 Increased irritability  \n􀂅 Crying spells  \n􀂅 Excessive worry  \n􀂅 Anxiety attacks  \n􀂅 Avoidance  \n􀂅 Hallucinations  \n􀂅 Suspiciousness  \n􀂅 Suicidal thoughts  \n􀂅 Self-harm (explain,  \n_______________________)  \n􀂅 Violent thoughts  \n􀂅 Violence toward others (anyone specific?)  \n_______________________  \n_______________________  \n􀂅 Other,    \n􀂅 Other,    \nSuicide Risk Assessment  \nHaǀe you eǀer had feeliŶgs or thoughts that you didŶ’t ǁaŶt to liǀe? 􀂅 Yes 􀂅 No If YES, please, answer the following. If NO, please, skip to the next section.  \nDo you ĐurreŶtly feel that you doŶ’t ǁaŶt to liǀe? 􀂅 Yes 􀂅 No  \nHow 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?   Would anything make it better?   Do you have a plan to kill yourself?   Is the method you would use readily available?   Is there anything that would stop you from killing yourself?   Do you feel hopeless and/or worthless?   Have you ever tried to kill yourself before?   Do you have access to guns, weapons, medications, or anything you can hurt yourself with?  \n2  \nEffective 1/03/17  \nSolutioŶs’ MeŶtal Health CliŶic IŶtake/Ass  \n􀂅 Yes 􀂅 No If YES, please, explain    \nMedical Information  \nAllergies:   Current Weight:   Current Height:    \nList A","cbCaij3ap7VymkDS","https://ap.wps.com/l/cbCaij3ap7VymkDS","pdf",257912,"English","# General Information\n## Insurance Information\n# iMind Mental Health and Wellness Intake\n## Services, Goals, and Symptoms Checklist\n## Suicide Risk Assessment\n# Medical Information\n## Personal and Family Medical History\n# Mental Health History/Status","[{\"question\":\"What information must be completed before the first visit?\",\"answer\":\"The form requests general demographics, contact details, emergency contact, supportive living and program manager information, and primary/secondary insurance details. It also asks for mental health service needs, reasons for treatment, and personal goals.\"},{\"question\":\"What sections are included to assess mental health status?\",\"answer\":\"It includes a mental health services selection, a current symptoms checklist, and a suicide risk assessment section with questions about prior thoughts, frequency, timing, planning, access to means, and hope or worthlessness.\"},{\"question\":\"What medical details does the form ask for?\",\"answer\":\"It collects allergies, current weight and height, and lists of all prescription medications with dosage and start dates, along with over-the-counter medications or supplements. It also requests pregnancy concerns for women and a summary of personal/family medical history and past hospitalizations or surgeries.\"}]","PATIENT INTAKE FORM - Intake - iMind Mental Health and Wellness | PDF",1789852206]