Patient Intake PART TWO - Kizaur Counseling

PATIENT INTAKE (PART TWO)

Thank you for taking the time to complete this information. Your intake will include four parts.

PART ONE: collecting general information about you and financial information for billing purposes
PART TWO: gathering biopsychosocial information (e.g., ranging from how you’re feeling today to habits and history)
PART THREE: reviewing Kizaur Counseling privacy practices
PART FOUR: consenting to being treated by Kizaur Counseling

After you complete each part of your intake and click the "SUBMIT" button, you will then be taken to the next part.

All the information you share during this process remains completely confidential and helps me better help you.

BIOPSYCHOSOCIAL INFORMATION

Your Name *

Who is your Primary Care Physician (PCP)? *

PCP Address *

Country

City

State

Zip code

PCP Phone Number *

Do you give me permission to contact your PCP? *

Are you presently seeing a specialist physician? If yes, being treated for? *

Do you have any chronic medical conditions? If you answer "YES," please specify below *

Any Allergies to food, medications, products, etc.? If you answer "YES," please specify below *

Any genetic information you’d like to share? If you answer "YES," please specify below *

Currently taking ANY prescription medications? If you answer "YES," please specify below *

Do you take vitamins or supplements? If you answer "YES," please specify below *

How would you rate your nutrition? (Poor, Okay, Good, Excellent) Please describe below *

Please describe any family psychiatric history: *

Please describe any psychiatric hospitalizations (voluntary or involuntary), diagnosis(es) and treatments below: *

Have you seen other mental health professionals? Please indicate when, diagnosis(es), and treatment planning used: *

Any family history of the following…if yes, please indicate family member and issue: *

Alcohol/Substance Abuse; Anxiety; Depression; Domestic Violence; Eating Disorders; Obesity; Obsessive Compulsive Behavior; Schizophrenia; Psychosis; Bipolar Disorder; Suicide Attempts

Describe your family of origin and your immediate family: *

Children? Please list name(s), age(s), and gender(s): *

Please describe your occupation and education: *

My current satisfaction with my work is: *

My current satisfaction with my leisure time is: *

Please review the following symptoms and then use the term that best describes you at present

	Never	Rarely	Sometimes	Often	Almost Always
Feelings of anger, irritability
Feelings of nervousness, anxiety
Feelings of depression, sadness
Difficulty concentrating
Difficulty getting to or falling back asleep
High Energy
Low Energy
Feelings of guilt or shame
Feelings of having no direction
Feeling as if you cannot cope
Mood swings
Hallucinations
Loss of Interest or pleasure
Memory problems
Obsessions or compulsions
Panic attacks
Paranoia or feelings of persecution
Phobias
Sexual problems or concerns
Self harm ideas
Self harm actions
Suicidal thoughts (Ideation)

	Never	Rarely	Sometimes	Often	Almost Always
Alcohol use
Recreational drug use
Feelings of no appetite
Feeling the need to control food intake
Feelings of dread or tremendous worry
Feelings of lacking achievement
Feel like I can handle issues in life as they arise
Feel like I have the capacity to change
Feelings of worthlessness
Feelings of despair
Thoughts about money issues
Feeling that others don’t understand me
Hide my true self
Difficulty trusting others
Difficulty letting go of control
Want to speak up but don’t let myself
Feel like my mind is going many directions at once
Feel out of balance
Feel disconnected from myself

Please rate & describe your current health below *

1-5 (5 being excellent)

Please rate & describe your current sleep habits below *

1-5 (5 being excellent) Please specify whether you dream or not

Please rate & describe your current exercise habits below *

1-5 (5 being excellent) Do you exercise? How often and what do you do?

Please rate & describe your Relationship/Marriage/Partnership below *

1-5 (5 being excellent) Please list six words that describe your relationship. If not in a relationship, state N/A.

Experiencing anxiety, panic attacks, or have phobias? *

Please describe:

Are you currently experiencing any chronic pain? *

Please describe:

Please briefly describe your spirituality/religious beliefs: *

Please describe:

Have any suicidal thoughts (Ideation) today? *

Y/N

Have you had any suicidal thoughts in the past? *

Y/N

Have you ever made any attempts to end your life? *

Please describe briefly:

Have you or your family recently experienced any major life changes? *

Please describe briefly:

In the past, have you experienced any major losses in life? *

Please describe briefly:

Would you consider yourself as currently grieving? *

Please describe briefly:

Substance Use: please review the intoxicants below and then use the term that best describes your use at present

If you are using an intoxicant NOT listed above, please describe

and please state for HOW LONG

For any intoxicant you answered "Seldom" "Often" or "Always"

please state for HOW LONG

Please briefly describe what has brought you to counseling today: *

Please indicate what you hope to get out of our counseling sessions together: *

Please list three words that describe who you are: *

What is something you really want me to know today: *

In this moment, I am____ because: *

If you selected "OTHER" above, please describe:

	Never	Seldom	Often	Always
Alcohol
Nicotine (cigarettes, vape)
Marijuana
Benzodiazepines
Ecstasy/MDMA
Cocaine/Crack
Hallucinogens
Opiates
Sedatives
Stimulants
Methamphetamines