Initial Psychiatric Intake Questionnaire

INITIAL PSYCHIATRIC INTAKE QUESTIONNAIRE

Reason for visit / main concerns

When did the problem begin?

What makes it better/worse?

Past psychiatric diagnoses/treatment/hospitalizations

Therapy history

Family psychiatric history

Medical history

Substance use (alcohol, cannabis, nicotine, stimulants, opioids, other)

Social/occupational/family stressors

Goals for treatment

Additional information you want the provider to know