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Veterans Choice Intake Form
First Name
*
Middle Initial
Last Name
*
SSN
*
Date of birth
*
+
Age
*
Gender
*
Male
Female
Street Address
*
Address Line 2
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
*
What is the preferred number to reach you at?
*
Home
Cell
Work
Other
Phone Number
*
Would you like to add another contact number?
*
Yes
No
Phone Number
Best time to call
*
7:30 - 9:00
9:00 - 12:00
12:00 - 3:00
3:00 - 5:00
Email Address
*
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.
*
Text
Call
I opt out
Cell Carrier?
*
Emergency contact information
Name
Phone number
Relationship
1
Name
Phone number
Relationship
2
Name
Phone number
Relationship
Referral Information
Who referred you to Family Care Center?
*
Name and number of your primary care physician if know?
Name and number of therapist if known?
Presenting Problem
The primary issue I am here to address is (check all that apply):
*
Trauma Adjustment Issues
Anxiety / Sleep Issues
Depression Problem Behavior
Hallucinations
Hopelessness
Avoidance
Memory / Concentration Issues
Grief / Loss
Substance Use / Abuse
Panic
Intrusive Thoughts
Disorientation
Relationship Issues
Anger
Suicidal Thoughts
Vocational Stress
Fatigue
Anxiety
Other
Other
Mental Health History
Prior
OUTPATIENT
psychotherapy?
*
Yes
No
How many times?
Dates if known.
+
-
Diagnosis
*
Therapist information
Name
City, State
Phone number
1
Name
City, State
Phone number
2
Name
City, State
Phone number
3
Name
City, State
Phone number
4
Name
City, State
Phone number
5
Name
City, State
Phone number
Treatment Modality (check all that apply)
Cognitive Processing Therapy
Cognitive Behavioral Therapy
EMDR
Prolonged Exposure
Dialectical Behavioral Therapy
Not Known
Other
Other
Which, if any, were beneficial?
Has any family member had any mental health treatment?
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Yes
No
Who and for what reason or diagnosis and where they given any medications? (list all here)
Prior
INPATIENT
treatment for psychiatric, emotional, or substance use disorder?
*
Yes
No
How many times?
Dates if known.
+
-
Diagnosis
*
Inpatient facility information
Name
City, State
Phone number
1
Name
City, State
Phone number
2
Name
City, State
Phone number
3
Name
City, State
Phone number
4
Name
City, State
Phone number
5
Name
City, State
Phone number
Treatment Modality (check all that apply)
Cognitive Processing Therapy
Cognitive Behavioral Therapy
EMDR
Prolonged Exposure
Dialectical Behavioral Therapy
Not Known
Other
Other
Which, if any, were beneficial?
Prior or current psychotropic medication use?
*
Yes
No
List all psychotropic medications below.
Medications
Dosage
Side Effects
Beneificial
Medication #1
Medications
Dosage
Side Effects
Beneificial
Medication #2
Medications
Dosage
Side Effects
Beneificial
Medication #3
Medications
Dosage
Side Effects
Beneificial
Medication #4
Medications
Dosage
Side Effects
Beneificial
Medication #5
Medications
Dosage
Side Effects
Beneificial
Medication #6
Medications
Dosage
Side Effects
Beneificial
Family History
Parents current marital status:
Married
Divorced
Seperated
Deceased
Present during your childhood:
Present Entire Childhood
Present Part of Childhood
Not Present at All
N/A
Mother
Present Entire Childhood
Present Part of Childhood
Not Present at All
N/A
Father
Present Entire Childhood
Present Part of Childhood
Not Present at All
N/A
Stepmother
Present Entire Childhood
Present Part of Childhood
Not Present at All
N/A
Stepfather
Present Entire Childhood
Present Part of Childhood
Not Present at All
N/A
Brother(s)
Present Entire Childhood
Present Part of Childhood
Not Present at All
N/A
Sister(s)
Present Entire Childhood
Present Part of Childhood
Not Present at All
N/A
Anybody else not listed above?
Describe childhood family experience: (check all that apply)
Outstanding home environment
Normal home environment
Chaotic home environment
Witnessed physical/verbal/sexual abuse towards others
Experienced physical/verbal/sexual abuse from others
Age of emancipation and circumstances if applicable:
🛈
Any other special circumstances in childhood that we should know about?
Current Marital Status:
Single, never married
Engaged
Married
Divorced
Seperated
Live-in partner
Number of Marriages for Self?
Number of Marriages for Partner?
Intimate Relationships:
Never been in a serious relationship
Not currently in a relationship
Currently in a serious relationship
Relationship Satisfaction:
Very satisfied
Satisfied
Somewhat satisfied
Dissatisfied
Very dissatisfied
List all persons currently living in your household.
Name
Age
M / F
Relationship to patient
1
Name
Age
M / F
Relationship to patient
2
Name
Age
M / F
Relationship to patient
3
Name
Age
M / F
Relationship to patient
4
Name
Age
M / F
Relationship to patient
5
Name
Age
M / F
Relationship to patient
List all children currently NOT living in same household as you.
Name
Age
M / F
Relationship to patient
1
Name
Age
M / F
Relationship to patient
2
Name
Age
M / F
Relationship to patient
3
Name
Age
M / F
Relationship to patient
4
Name
Age
M / F
Relationship to patient
5
Name
Age
M / F
Relationship to patient
Frequency of visitation of above.
Describe any past or current significant issues in intimate relationships.
Describe any past or current significant issues in other immediate family relationships.
Medical History (check all that apply)
Describe your current health.
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Good
Fair
Poor
List any known allergies or put NKA.
*
Is there a history of the following in the family?
*
Tuberculosis
Birth defects
Emotional problems
Thyroid problems
Cancer
Mental retardation
Heart disease
High blood pressure
Alcoholism
Drug abuse
Diabetes
Alzheimer's disease / dementia
Stroke
Other
Other
Any other medications being taken not previously mentioned?
*
Yes
No
List any medications currently being taken.
Medication
Dosage
Reason
1
Medication
Dosage
Reason
2
Medication
Dosage
Reason
3
Medication
Dosage
Reason
4
Medication
Dosage
Reason
5
Medication
Dosage
Reason
Any serious hospitalizations or accidents?
*
Yes
No
Describe.
Date
Age
Reason
1
Date
Age
Reason
2
Date
Age
Reason
3
Date
Age
Reason
4
Date
Age
Reason
Any abnormal labs?
*
Yes
No
Describe.
Date
Result
1
Date
Result
2
Date
Result
3
Date
Result
4
Date
Result
Name and phone number of psychiatrist if known.
Substance Use History
Substances Used:
Alcohol
*
Yes
No
First use age
Last use age
Current use Y or N
Frequency
Amount
1
First use age
Last use age
Current use Y or N
Frequency
Amount
Amphetamines/speed
*
Yes
No
First use age
Last use age
Current use Y or N
Frequency
Amount
1
First use age
Last use age
Current use Y or N
Frequency
Amount
Barbiturates
*
Yes
No
First use age
Last use age
Current use Y or N
Frequency
Amount
1
First use age
Last use age
Current use Y or N
Frequency
Amount
Cocaine
*
Yes
No
First use age
Last use age
Current use Y or N
Frequency
Amount
1
First use age
Last use age
Current use Y or N
Frequency
Amount
Crack cocaine
*
Yes
No
First use age
Last use age
Current use Y or N
Frequency
Amount
1
First use age
Last use age
Current use Y or N
Frequency
Amount
Hallucinogens (e.g., LSD)
*
Yes
No
First use age
Last use age
Current use Y or N
Frequency
Amount
1
First use age
Last use age
Current use Y or N
Frequency
Amount
Inhalants (e.g., glue, gas)
*
Yes
No
First use age
Last use age
Current use Y or N
Frequency
Amount
1
First use age
Last use age
Current use Y or N
Frequency
Amount
Marijuana or hashish
*
Yes
No
First use age
Last use age
Current use Y or N
Frequency
Amount
1
First use age
Last use age
Current use Y or N
Frequency
Amount
Nicotine/cigarettes
*
Yes
No
First use age
Last use age
Current use Y or N
Frequency
Amount
1
First use age
Last use age
Current use Y or N
Frequency
Amount
PCP
*
Yes
No
First use age
Last use age
Current use Y or N
Frequency
Amount
1
First use age
Last use age
Current use Y or N
Frequency
Amount
Prescription drugs
*
Yes
No
Which drug if yes?
Which drug if yes?
First use age
Last use age
Current use Y or N
Frequency
Amount
1
First use age
Last use age
Current use Y or N
Frequency
Amount
Others not listed
*
Yes
No
Which drug if yes?
Which drug if yes?
First use age
Last use age
Current use Y or N
Frequency
Amount
1
First use age
Last use age
Current use Y or N
Frequency
Amount
Consequences of substance use
Hangovers
Blackouts
Tolerance changes
Suicidal ideations
Withdrawal symptoms
Sleep disturbance
Binges
Seizures
Medical conditions
Assaults
Job loss
Arrests
Overdose
Loss of control
Relationship conflicts
Other
Other
Have you ever had treatment for substance abuse
*
Yes
No
Substance use treatment history
Age
Successful
Outpatient
Age
Successful
Inpatient
Age
Successful
12-step program
Age
Successful
Stopped on own
Age
Successful
Other
Age
Successful
Family substance abuse history
*
Check all that apply
yes
no
N/A
Father
yes
no
N/A
Mother
yes
no
N/A
Grandparents(s)
yes
no
N/A
Sibling(s)
yes
no
N/A
Step-parent / live-in
yes
no
N/A
Uncle(s) / Aunt(s)
yes
no
N/A
Spouse / significant other
yes
no
N/A
Children
yes
no
N/A
Other
yes
no
N/A
Socio-Economic History (check all that apply)
Housing situation:
*
Adequate
Homeless
Overcrowed
Dependent on others for housing
Dangerous / deterioration
Living companion's dysfunctional
Employment:
*
Employed and satisfied
Employed but dissatisfied
Unemployed
Coworker conflicts
Supervisor Conflicts
Unstable work history
Disabled
Financial Situation:
*
No problems
Large indebtedness
Poverty or below-poverty income
Impulsive spending
Relationship conflicts over finances
Social support system:
*
Supportive network
Few friends
Substance-use-based friends
No friends
Distant from family of orgin
Legal history
*
Check all that apply
yes
no
Current or past legal problems
yes
no
on parole / probation
yes
no
Arrest(s) not substance use related
yes
no
Arrest(s) substance use related
yes
no
Court ordered for this treatment
yes
no
Jail / prison
yes
no
If applicable, how many times have you been to jail / prison and what is the total time served?
If applicable, describe last legal difficulty.
Activities
Yes
No
Currently active in community / recreational activities
Yes
No
Formerly active in community / recreational activities
Yes
No
Currently engage in hobbies
Yes
No
Currently engage in spiritual activities
Yes
No
Sexual Orientation
*
Heterosexual
Homosexual
Bisexual
Choose not to disclose
Currently sexual active?
Yes
No
Sexually satisfied?
Yes
No
If applicable, age of first sexual experience
If applicable, age of first pregnancy / fatherhood
History of promiscuity?
*
Yes
No
How long did it go on?
Youngest age
Oldest age
Age
Youngest age
Oldest age
History of unsafe sex?
*
Yes
No
How long did it go on?
Youngest age
Oldest age
Age
Youngest age
Oldest age
Ethnicity
Religion
Describe any cultural issues that contribute to current problem:
Describe if answering "Yes" to any of the above.
Military History
Branch of Service
*
Army
Navy
Air Force
Marines
Coast Guard
Enlistment Date
*
+
Discharge Date
*
+
Military occupation.
Highest rank / grade held?
Rank / grade at discharge?
Characterization of discharge?
Honorable
General
Other than honorable
Dishonorable
Chaptered
Medically Boarded
Deployed
*
Yes
No
Number of deployments.
Deployment dates and location.
+
-
Unit's Mission.
+
-
Notices
Patient Grievances
Patient Rights
Non-discrimination Notice
Notice of Privacy Practices
Financial Agreement
By checking this box, you acknowledge that you have read the notices above.
*
Agree
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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