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Behavioral Health Intake Form
General Information
Today's Date
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First Name
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Last Name
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Preferred Name
Date of Birth
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Primary Language
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English
Spanish
Other:
Other:
Gender Identity
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Androgynous
Demigender
Female
Gender Expansive
Gender Fluid
Gender Non-Confirming
Gender Queer
Intersex
Male
Non-Binary
Questioning
Trans Male/ Tans Masc.
Trans Woman/ Trans Fem.
Two-Sprit
Other
Other
Sexual Orientation?
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Asexual
Bisexual
Gay
Heterosexual/Straight
Intersex
Lesbian
Pansexual
Prefer Not To Say
Queer
Questioning or Unsure
Same Gender Loving
Other
Other
Gender Pronoun
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He, His
She, Her
They, Them
Ze, Hir/Zir
Other
Other
Contact Information
Current Address (If no address put "N/A" )
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
Email Address (If no email type "N/A")
Best Number To Reach You
Can Voicemail Messages Be Left For You To Receive?
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No
Yes
N/A
Aside Fom Telephone Calls, Please Let Us Know How You Would Like To Receive Information and Notifications From Our Team.
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Email
Text Message
Voicemail
Personal Information
What Is Your Current Living Situation?
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Alone
Assisted Living
Car/Mobile Home
Crisis Residential
Experiencing Homelessness
Rents A Room/ With Roommates
Substance Treatment Facility
Transitional Living
With Friends
With Other Relative(s)
With Same Sex Partner
With Spouse
With Spouse and Children
Other
Other
Current Relationship Status?
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Divorce
Domestic Partner
Married
Partnered
Separated
Single/ Never Married
Widowed
Do You Have Children?
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No
Yes
Unsure
Ethnicity
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Hispanic
Not Hispanic
Race
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American Indian/ Alaska Native
Asian
Black/ African American
Caucasian/White
Latino/a/x
Mexican American
Native Hawaiian/Other Pacific Islander
Other:
Other:
Grade of Education Last Completed
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6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
Associate Degree
Bachelors Degree
General Educational Development (GED)
High School Diploma
Masters Degree
Some College
Are You A Current Student?
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No
Yes
Do You Have Current or Prior Military Service?
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No
Yes
Who Did You Grow Up With?
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Extended Family Member (Grandparents, etc.)
Foster Parents
One Immediate Family Member (Single Parent)
Two Immediate Family Members
Other
Other
What Is Your Income Source(s)?
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Disability (SSDI)
Employed
Family/Friends
GR /GR Housing Subsidy
None
Social Security (SSI)
Unemployed
Unemployment (EDD)
Other
Other
Health Questionaire
What Is Your Overall Health?
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Excellent
Good
Fair
Poor
Have You Ever Been In Counseling/Therapy Services?
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No
Prefer Not To Disclose
Yes
If Yes, When? Also, What Were The Most Helpful and Least Helpful Parts Of Your Prior Therapeutic Experience(s)?
In The Last 2 Weeks Have You Used Any Substances?
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No
Prefer Not To Disclose
Yes
If Yes, What Substances Have You Used (If No, Type "N/A")?
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Are You Currently Taking Any Medications?
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No
Prefer Not To Disclose
Yes
If Yes, What Medications Are You Taking?
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Do You Have Any Preferences For A Counselor?
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No
Yes
If Yes, What Is Your Preference(s)?
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What Is Your Availability?
0/255 characters
Level Of Care Services?
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Outpatient (OP) Behavioral Health Services (Office Visit)
Online Counseling Services (Video or Audio)
Reason For Referral To Mental Health Services/Therapy.
Please Check All That Apply.
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Academic Underachievement
Alcohol Abuse
Anger outbursts
Anxious/worries
Behavioral Issues
Bullying/Threatens others
Codependency
Coping Skills
Defiant/oppositional
Delusions
Depressed/sad
Divorce
Eating issues
Grief/loss
Hallucinations
Hyperactive
Impulsive
Inability to focus
Infidelity
Irritable
Panic attacks
Parenting
Peer Relationship
Self-harm
Sexual abuse
Sexualized behaviors
Sleep issues
Substance use
Suicidal or homicidal ideation
Tantrums
Trauma and PTSD
Urgent psychiatric meds
Violent/aggressive
Withdrawn/isolates
Other:
Other:
Over The Past 2 Weeks, How Often Have You Been Bothered By Any Following Problems?
1. Little Interest Or Pleasure In Doing Things.
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Not at all
Several days
More than half the days
Nearly every day
2. Feeling Down, Depressed, or Hopeless.
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Not at all
Several days
More than half the days
Nearly every day
3. Trouble Falling Asleep or Staying Asleep, or Sleeping Too Much.
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Not at all
Several days
More than half the days
Nearly every day
4. Feeling Tired or Having Little Energy.
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Not at all
Several days
More than half the days
Nearly every day
5. Poor Appetite or Overeating.
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Not at all
Several days
More than half the days
Nearly every day
6. Feeling Bad About Yourself -- or That You Are A Failure or Have Let Yourself or Your Family Down.
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Not at all
Several days
More than half the days
Nearly every day
7. Trouble Concentrating On Things, Such As Reading The Newspaper or Watching Television.
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Not at all
Several days
More than half the days
Nearly every day
8. Moving or Speaking So Slowly That Other People Could Have Noticed Or The Opposite -- Being So Fidgety or Restless That You Been Moving Around A Lot More Than Usual.
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Not at all
Several days
More than half the days
Nearly every day
9. Thoughts That You Would Be Better Off Dead, or Of Hurting Yourself In Some Way.
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Not at all
Several days
More than half the days
Nearly every day
10. If You Are Experiencing Any Of The Above Problems, How Difficult Have These Problems Made It For You To Do Your Work, Take Care Of Things At Home, Or Get Along With Other People?
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Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
The undersigned client* or responsible adult** consents to and authorizes mental health services by: The AMAAD Institute These services may include psychological testing, psychotherapy/counseling, rehabilitation services, medication, case management, laboratory tests, diagnostic procedures, and other appropriate services. While these services may be delivered at a different location, services provide within the Los Angeles County mental health system will be coordinated by the staff of a single agency.
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