Veterans Choice Intake Form

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Gender *
Would you like to add another contact number? *
Best time to call *
We provide courtesy appointment reminders. If you would like to receive a reminder, please let us know which method you prefer or you may opt out. Standard messaging rates may apply for texts. Confirmation reminders are a courtesy only. It is still your responsibility to make all your appointment. *
Emergency contact information
 NamePhone numberRelationship
1
2

Referral Information

Presenting Problem

The primary issue I am here to address is (check all that apply): *
 

Mental Health History

Prior OUTPATIENT psychotherapy? *
Dates if known.
Therapist information
 NameCity, StatePhone number
1
2
3
4
5
Treatment Modality (check all that apply)
 
Has any family member had any mental health treatment? *
Prior INPATIENT treatment for psychiatric, emotional, or substance use disorder? *
Dates if known.
Inpatient facility information
 NameCity, StatePhone number
1
2
3
4
5
Treatment Modality (check all that apply)
 
Prior or current psychotropic medication use? *
List all psychotropic medications below.
 MedicationsDosageSide EffectsBeneificial
Medication #1
Medication #2
Medication #3
Medication #4
Medication #5
Medication #6

Family History

Parents current marital status:
Present during your childhood:
 Present Entire ChildhoodPresent Part of ChildhoodNot Present at AllN/A
Mother
Father
Stepmother
Stepfather
Brother(s)
Sister(s)
Describe childhood family experience: (check all that apply)
Current Marital Status:
Intimate Relationships:
Relationship Satisfaction:
List all persons currently living in your household.
 NameAgeM / FRelationship to patient
1
2
3
4
5
List all children currently NOT living in same household as you.
 NameAgeM / FRelationship to patient
1
2
3
4
5

Medical History (check all that apply)

Describe your current health. *
Is there a history of the following in the family? *
 
Any other medications being taken not previously mentioned? *
List any medications currently being taken.
 MedicationDosageReason
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2
3
4
5
Any serious hospitalizations or accidents? *
Describe.
 DateAgeReason
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2
3
4
Any abnormal labs? *
Describe.
 DateResult
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2
3
4

Substance Use History

Substances Used:
Alcohol *
 First use ageLast use ageCurrent use Y or NFrequencyAmount
1
Amphetamines/speed *
 First use ageLast use ageCurrent use Y or NFrequencyAmount
1
Barbiturates *
 First use ageLast use ageCurrent use Y or NFrequencyAmount
1
Cocaine *
 First use ageLast use ageCurrent use Y or NFrequencyAmount
1
Crack cocaine *
 First use ageLast use ageCurrent use Y or NFrequencyAmount
1
Hallucinogens (e.g., LSD) *
 First use ageLast use ageCurrent use Y or NFrequencyAmount
1
Inhalants (e.g., glue, gas) *
 First use ageLast use ageCurrent use Y or NFrequencyAmount
1
Marijuana or hashish *
 First use ageLast use ageCurrent use Y or NFrequencyAmount
1
Nicotine/cigarettes *
 First use ageLast use ageCurrent use Y or NFrequencyAmount
1
PCP *
 First use ageLast use ageCurrent use Y or NFrequencyAmount
1
Prescription drugs *
 
 First use ageLast use ageCurrent use Y or NFrequencyAmount
1
Others not listed *
 
 First use ageLast use ageCurrent use Y or NFrequencyAmount
1
Consequences of substance use
 
Have you ever had treatment for substance abuse *
Substance use treatment history
 AgeSuccessful
Outpatient
Inpatient
12-step program
Stopped on own
Other
Family substance abuse history *
Check all that apply
yesnoN/A
Father
Mother
Grandparents(s)
Sibling(s)
Step-parent / live-in
Uncle(s) / Aunt(s)
Spouse / significant other
Children
Other

Socio-Economic History (check all that apply)

Legal history *
Check all that apply
yesno
Current or past legal problems
on parole / probation
Arrest(s) not substance use related
Arrest(s) substance use related
Court ordered for this treatment
Jail / prison
Activities
 YesNo
Currently active in community / recreational activities
Formerly active in community / recreational activities
Currently engage in hobbies
Currently engage in spiritual activities
Currently sexual active?
Sexually satisfied?
History of promiscuity? *
How long did it go on?
 Youngest ageOldest age
Age
History of unsafe sex? *
How long did it go on?
 Youngest ageOldest age
Age

Military History

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Deployed *
Deployment dates and location.
Unit's Mission.

Notices

By checking this box, you acknowledge that you have read the notices above. *

Acknowledgement and Signature

By signing this form, you agree that you are willing to be seen by a provider at the Family Care Center and will become a client of this clinic upon submission of this form. Two or more no-shows for an initial appointment can result in you not being accepted as a client. *
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