ARTWORKS Intake Form

 

49 Church Street, Norwich, CT 06360 (860) 889-2413 Fax:(860)383-8108

artworks4u2@gmail.com

 

Today’s Date:

 

 

Last Name: First Name:    Middle Initial:

                

Social Security Number: - -

 

Name of parent/guardian (if under 18):

DCF Involvement? Yes No N/A

If yes, DCF Social Worker/Case Manager: DCF Contact Number:

 

Birth Date:  Age:  Gender:  Male Female

 

Street Address:

 

City: State:  Zipcode:

 

Home Phone:  May we leave a message? Yes No

Cell/ other phone:  May we leave a message? Yes No

 

Email:

“Please note: email correspondence Is not considered to be a confidential medium of communication.

 

Marital Status: Never Married Married Domestic Partnership Separated Divorced Widowed

 

Please list any children/ ages:

Please list any siblings/ ages:

Have any children/ siblings previously received therapy at Artworks or currently receiving therapy at Artworks? Yes No

If yes, please list:

Please list dates of attendance:  to  

 

Referred by (if any):

 

Last school attended:  Highest education level completed:

 

Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)? Yes No

 

If yes, previous therapist/ practitioner:

 

What is your medical history?

 

Are you using any medications presently? Yes No

If yes, please list:

 

Have you ever been prescribed psychiatric medications? Yes No

If yes, please list and provide dates:

 

Do you have any history of abuse? Yes No

If yes, please explain:

 

 

Do you have any experience with Art Therapy or art making? Yes No

(Please note: Art experience or art interest is not required.)

 

GENERAL HEALTH AND MENTAL HEALTH INFORMATION

 

How would you rate your current physical health? (please select one)

Very Good    Good             Satisfactory  Unsatisfactory             Poor

 

Please list and specific health problems you are currently experiencing:

 

How would you rate your sleeping habits? (please select one)

Very Good    Good             Satisfactory  Unsatisfactory             Poor

 

Please list any specific sleep problems you are currently experiencing:

 

How many times per week do you generally exercise?

 

What types of exercise do you participate in?

 

Please list any difficulties you experience with your appetite or eating patterns:

Are you currently experiencing overwhelming sadness, grief, or depression? Yes No

If yes, for approximately how long?

 

Are you currently experiencing anxiety, panic attacks, or have any phobias? Yes No

If yes, when did you begin experiencing this?  

 

Are you currently experiencing chronic pain? Yes No

If yes, please describe:

Do you drink alcohol? Yes No

If so, how often?

How often do you engage in recreational drug use? Never Infrequently Monthly Weekly Daily

 

Are you currently in a romantic relationship?    Yes No

If yes, for how long?

On a scale of 1-10, how would you rate your relationship?

What significant life changes or stressful events have you experienced recently?

 

FAMILY MENTAL HEALTH HISTORY

 

In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (father, grandmother, uncle, etc.)

 

Alcohol/Substance Abuse                     Yes No                Family Member:

 

Anxiety                                                       Yes No                Family Member:

 

Depression                                               Yes No                Family Member:

                                 

Domestic Violence                                  Yes No                Family Member:

 

Eating Disorders                                      Yes No                Family Member:

 

Obesity                                                       Yes No                Family Member:

 

Obsessive Compulsive Behavior        Yes No                Family Member:

 

Schizophrenia                                          Yes No                Family Member:

 

Suicide Attempts                                      Yes No                Family Member:

 

ADDITIONAL INFORMATION

 

Are you currently employed? Yes No

 

If yes, what is your current employment situation?

 

Do you enjoy your work? Yes No

Is there anything stressful about your current work?

Do you consider yourself to be spiritual or religious? Yes No

 

If yes, describe your faith or belief:

 

What do you consider to be some of your strengths?

 

 

What do you consider to be some of your weaknesses?

 

What would you like to accomplish out of your time in therapy?

 

Payment Information/ Client Insurance information

 

What insurance coverage do you have?

 

Policy Number:

 

DCF Funding/ Flex Spending? Yes No N/A

 

Other Payment source: