Intake Form Dr. Nancy Jordan Intake Form Step 1 of 9 – New Client Information 11% Nancy Jordan, Ph.D. 4646 Poplar Ave., Suite 320, Memphis, TN 38117 New Client InformationIdentifying Information(Required) First Name Last Name Date(Required) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Daytime Phone(Required)Evening Phone(Required)Cell(Required)FaxEmail(Required) Age(Required) Marital Status Emergency Contact (Please list your emergency contacts):(Required) First Last Emergency Contact #2 First Last Responsible Party: (If someone other than client is responsible, please complete the following) First Name Last Name Responsible Party Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Responsible Party Phone Therapy Goals ChecklistIn order to offer you the treatment opportunities most in line with your reasons for coming to this office, please mark all items listed below that currently reflect your treatment goals Better managing stress Better managing anger Addressing grief and loss Improving my sleep Losing weight Gaining weight Improving my body image Feeling better about myself Addressing spiritual issues Reacting less emotionally Improving my relationships Addressing past trauma Stopping smoking Taking better care of my physical health Better managing my pain condition Learning how to relax Learning about exercises that I can do Decreasing fears and worries Managing thoughts of harming myself or others Learning about medications to help with my mood Feeling less depressed Feeling less anxious or nervous Better managing unwanted thoughts Learning about a diagnosis 1. Please review the items you have marked. Which three areas do you most wish to address at this time:2. How certain are you that you will be able to make changes in these areas? Very uncertain A little uncertain Becoming more certain Certain Very Certain 3. How motivated are you to begin making these changes? Not at all motivated to change Thinking about making changes Planning to change I’m already making changes I’ve successfully made the changes I want to make Adult Symptom ChecklistPlace mark all of the symptoms listed below if your have experienced them in the past or are currently: Feeling depressed, sad, blue Loss of interest in activities Sleep problems Low energy/fatigue Feeling irritable/angry Memory or concentration problems Withdrawing from others/isolating Thoughts of harming yourself Thoughts of harming others Hearing voices Seeing things others don’t see Thoughts that others are trying to hurt you Thoughts that you can’t get out of your head Feeling nervous/anxious Panic attacks Racing thoughts Counting, checking, arranging/rearranging Washing hands too much Too much energy Spending too much money Engaging in dangerous activities on purpose Forced vomiting after eating Poor appetite Overeating Weight gain or loss Exercising too much Restricting food Drinking too much alcohol Using street drugs Gambling Abuse Domestic Violence Relationship problems Family problems Cutting, scratching or burning yourself Pulling your hair out Other Please specify: Primary Concerns1. Please describe the primary concern that brought you to this office:2. What led to your decision to seek help at this time?3. How severe is the concern for you at this time? Mildly upsetting Moderately upsetting Severe Very severe Extremely severe 4. When did the problem/concern begin? What do you think triggered it?5. What have you done to cope with or manage the problem/concern?6. Is there anything else, now or in the past, which has been very stressful for you?7. How would you describe your mood during the past week: Depressed Irritable Anxious Good Other 8. Please describe your strengths: Medical History1. Do you receive regular medical care from a physician or clinic? Yes No Physician's Name First Last Physician's PhonePhysician's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Physician's Name First Last Physician's PhonePhysician's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 2. When was your last complete physical examination? 3. Please list your prescription medication(s): Add RemovePress the (+) to list an additional medication 4. Please list any vitamins, herbal remedies, or over-the-counter medications that you take: Add RemovePress the (+) to list an additional medication 5. Please mark if you have ever had any of the following illness, injuries, or medical events: High blood pressure Migraine headaches Diabetes Other headaches Cancer* Colitis Fibromyalgia Irritable bowel syndrome Thyroid disease Tuberculosis Stroke* Head injury* Asthma COPD/emphysema Seizures* Sleep apnea Hormone problems* Premenstrual syndrome Chronic pain* Heart disease Multiple sclerosis Peptic/stomach ulcers Hospitalizations*: Surgeries*: Chemical exposure*: Other*: Hepatitis * Please describe:6. Please mark all symptoms that apply to you: Dizziness Muscle spasms Heart skipping beats Tension Headaches Tremors Stomach problems Chest pain/tightness Rapid heart beat Fatigue Blackouts Sweating Fainting Bladder problems Bowel problems Shortness of breath Skin problems Sexual problems Cold all the time Overweight Appetite changes Lumps anywhere Hot spells/flashes Sleep problems Weight changes Coughing or wheezing Memory problems Morning headaches Snoring Menstrual problems Pain problems Hearing problems Visual problems Speech problems Falling down Unusual or excessive thirst Legs jerking Daytime sleepiness Psychological/Psychiatric HistoryHidden1. Have you ever been treated for mental health issues? Yes No If yes, when and by whom? 2. Please list any/all mood medication(s) you are taking now and how often you take them:3. Please list any mood medication(s) you have taken in the past but and reason you stopped them:4. What type(s) of psychotherapy have you received in the past? None Individual Group Family 5. If you have been hospitalized for mental health reasons, please list when, where, for how long, and for what reason:Please mark if any of the following are true: Have you ever thought about suicide? Have you recently thought about suicide? Have you ever attempted suicide? Has anyone in your family ever attempted suicide? Have you recently thought about physically injuring/hurting someone? Have you ever physically injured/hurt someone? Have you ever been a victim of domestic violence? Have you ever been a victim of abuse of any kind? Are you currently in an abusive relationship? Are you aware of services available to victims of abuse/domestic violence? Social History1. What is your current marital/relationship status? Single Married Divorced Separated Engaged In a committed relationship a. How long have you been married or in this relationship? b. How would you rate your overall satisfaction with the relationship? Very unsatisfied Unsatisfied Neutral Satisfied Very satisfied c. Please list any relationship issues or concerns that you would like to address:d. How many times have you ben married?2. How many children do you have? Please indicate their age, gender, and the quality of relationship to them.3. Who else lives in your home? 4. What is your current occupational status? Employed Unemployed Retired Disabled a. If employed: What is your occupation? Where do you work? How long? How satisfied are you with your current employment?b. If disabled: For what reason? How long? What type of work did you previously do?c. If retired: What type of work did you previously do? When did you retire?d. If unemployed: For how long? For what reason?e. Are you in the process of filing a disability claim? Yes No Is your visit to this office in anyway related to this claim?(Required) Yes No 5. Describe your school life experience. For example: grades, your favorite subject, learning difficulties, behavioral problems (skipping class, fighting, suspensions, drug/alcohol, etc.)6. Are you currently experiencing any legal problems? Yes No Have you experienced legal problems in the past? Yes No Please explain in detail regarding legal problems:(Required)7. Did you serve in the military? Yes No If so, please include branch, date of service, reason for leaving, etc.8. Do you have continuing involvement in religious or spiritual activities? Yes No What is your religious preference? Are you satisfied with the spiritual dimension in your life?9. Please indicate your social habits Alcohol Street drugs Caffeine (coffee, soda, tea, chocolate, NoDoz, energy drinks) Tobacco Diet Pills Hobbies Exercise None Please describe the activity and how you frequent them Family History1. Where were you born? 2. Where were you raised? 3. Please list your immediate family and describe your relationship with them:4. Did you suffer any abuse or trauma as a child? Yes No Regarding question 4, please describe your abuse/trauma: 5. If applicable, please describe any known problems or complications with your birth: 6. If applicable, please describe any significant childhood illnesses or injuries: 7. Did any of your family members have mental health problems? Yes No If so, indicate who and what type of problem(s):8. Did any of your family members abuse alcohol or drugs? Yes No If so, please indicate who and the substance abused: Other Important InformationPlease describe/list anything else that is important for us to know about that you have not written on any of these forms:Signature(Required) First Last Δ
