Intake Form

File No ……………………… Date …………………………. Name …………………………………………………………………….

Sex……………………………. Date of Birth …………………………. Age…………………….….....
Marital Status: S / M / D / Sep Present
Address……………………………………………………………………………………………
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Permanent Address ……………………………………………………………………………………….
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Phone……………………………. Education…………………… Occupation…………………………
Father’s Name…………………….. Age …….. Education ………… Occupation ……………….....
Mother’s Name ……………………. Age …….. Education ………… Occupation …………………..
Spouse’s Name …………………… Age …….. Education ………… Occupation …………………..
Siblings: M…………. F…………….. B.O. ……………… Children (Sex/Age) 1 ……………………. 2 …………………….. 3
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…………………….. 9 ……………………………….. Family Structure (Nuclear/joint)
…………………………………………………………………………. Head of Family ………………………………….
Earning Members ………………………………...... Income Group …………………………………
. Heritage ……………………………….................... Languages…………………………....................
Appearance………………………………………….. Informant’s Name…………………………………
Relationship………………………………
Informant’s Address/contact ……………………………………………………………………………... Referred by
………………………………………………………………………………………………… Presenting
Problems(Verbatim)…………………………………………………………………………...
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Assigned to: (For assessment) …………………………………………………………………………...
(For Therapy) ………………………………………………………………………………………………
Intake by…………………………………………………………………………………………………….
Other Information ………………………………………………………………………………………….
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Tentative Diagnosis ……………………………………………………………………………………….
Date of Termination………………………………………………………………… Unilateral/Bilatera
Patient’s Name…………………………………………………… Case No…………………………….

Father’s Name……………………………………………………………………………………………...

Intake by………………………………………… Date of Intake………………………………………...

Presenting Problems (Nature of presenting problems, Precipitating event, Patient’s thoughts and
feelings about problem ………………………………………………………………………………
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History of Problems (Duration of present problem, changes in nature, intensity, and/ or frequency of
problem over time, prodromal manifestations, other past problems of a psychological nature, No of
attacks ……………………………………………………………………..
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Prior Treatment (details of treatment sought for presenting problems and from whom, when and for
what duration treatment undergone: nature of treatment methods: names and dosages of drugs taken:
ECTs, faith healing etc.; response to treatment including adverse reactions and / or side effects
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4 Medical History (most recent physical exam, date and results, current medications, health condition
since childhood including details of serious illness/disabilities suffered and surgery undergone, eating
and sleeping habits if remarkable and any change of same, use of stimulants, alcohol or other drugs
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Family History (migrations, births, marriages, serious illnesses, jobs of earning members, relationships
with family members) ……………………………………………………………………...
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School History (marks/grades obtained, school changes, school problems, relationships with peers and
teachers, extra-curricular activities) …………………………………………………………
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Work Hsitory (nature of jobs held and remuneration, reasons for job changes, relationships with juniors,
colleagues and bosses) …………………………………………………………………………
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History of Friendships (nature and extent of relationships, recreational activities, degree of religiosity,
sexual history, premarital, marital and extramarital sexual relationships) ………………
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5 Additional Information ……………………………………………………………..................................

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Orientation (person, place, time) ………………………………………………………………………...

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Sleep (insomnia, nightmares, sleepwalking) …………………………………………………………...
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Attention (concentration, memory) ………………………………………………………………………

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Perception (illusion, hallucinations-auditory, visual, tactile, somatic, olfactory) …………………….

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Thought (unusual content including suspiciousness and delusion, conceptual disorganization including
loosening of associations) …………………………………………………………………….
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Affect (crying spells, depression, guilt feelings, suicidal, excitement, grandiosity, blunted affect)
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6 Behavior ( speech: mute, talkative, abusive, Motor: restless, assaulting, destructive, excited, motor
retardation …………………………………………………………………………………………..
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Mannerism and Posturing (unusual gestures, preservative movements) …………………………...

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Anxiety (tension, nervousness, phobias, obsessions/compulsions) …………………………………

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Somatoform (conversion, hypochondriasis other somatic complaints) ……………………………...

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Psychosexual (gender identity, paraphilia’s, psychosexual dysfunction) ……………………………
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Psychosomatic (obesity, headaches, painful menstruation, skin disorders, asthma, ulcers, nausea and
vomiting) ……………………………………………………………………………………..
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Addictions (prescribed and non-prescribed medications, narcotics use, smoking, pan/tobacco chewing,
alcohol use, gambling) …………………………………………………………………………
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Family Psychopathology (nature, history and treatment of mental disorders in members of patient’s
family) …………………………………………………………………………………………….
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7 Personality traits (paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic,

avoidant, dependent, obsessive compulsive, passive aggressive) ………………………………….
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Interview behavior (open, secretive, anxious, relaxed, withdrawn, cooperative, timid, aggressive,
compliant, opposition) …………………………………………………………………………………….
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Strengths (degree of insight, motivation, intellectual level, mitigating circumstances, other talents and
resources ……………………………………………………………………………………..
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Tentative Diagnosis ……………………………………………………………………………………….

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Recommendations (also list tests) ………………………………………………………………………

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Final Diagnosis …………………………………………………………………………………………….
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Date of termination ………………………………………………………………………………………..

………………………………………………………………………………………………………………. Reasons for termination
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