Clinical Intake Form for Adults
EVMS Psychiatry & Behavioral Sciences /

MRN:

Date:

Time:

Office Use Only: ______
Name:(First M.I. Last) /  M /  F / DOB:
Address: (Street, Apt#) / City, State, & ZIP:
Phone (home): / May a message be left? / Yes / No
Phone (cell/work): / May a message be left? / Yes / No

Primary Insurance:

/

Insurance Phone &

ID No.:

Secondary Insurance:

/

Insurance Phone &

ID No.:

(if applicable)

Policy Holder’s Name:

/ Email Address:

Race:

/ Ethnicity: / Language(s):
Occupation/Employer: / Education level: / # of Children:
Referred By: / PCP:

Marital status:

/  Single /  Partnered /  Married /  Separated /  Divorced /  Widowed
Service you are seeking:
(Please choose only ONE) /  Individual Therapy ONLY /  Evaluation Only for Bariatric or Transplant Surgery
 Med Evaluation/Management ONLY /  Evaluation Only for (second opinion on diagnosis, etc.)
 Individual Therapy Med Evaluation/Management /  ______

Reason(s) for seeking treatment:

/  Abuse /  Behavioral Problems /  Eating Disorder (height ______weight ______) /  Stress
 Anxiety/Panic /  Bipolar Disorder /  Grieving /  Trauma
 Attention Problems /  Depression /  Relationship Issues / Other______
How long have you experienced the problems checked off above?
Is this your first time requesting treatment by a psychiatrist and/or a psychologist? / Yes / No
If no, when was the last time you were seen and who were you seen by?
Have you had any previous psychiatric hospitalizations? / Yes / No
Have you ever attempted suicide? / Yes / No
****If you currently experience suicidal or homicidal thoughts, please dial 911 or go to your nearest emergency room. ****
Do you drink alcohol (beer/wine/liquor)? /  Yes /  No / How often?: Rarely Occasionally Frequently Consistently
Do you use recreational drugs (marijuana/cocaine/heroin)? /  Yes /  No / How often?: Rarely Occasionally Frequently Consistently
Are you currently involved in any legal proceedings (lawsuits, divorce, child custody, etc.)? / Yes / No
Do you have any pending disability claims OR do you plan to file a disability claim in the near future? / Yes / No
Any medical problems? If yes, please list the most severe: / Yes / No
Medications (Rx & OTC):
Are you having any difficulty sleeping (falling asleep, staying asleep, and/or waking frequently)? / Yes / No
Are you having any difficulty with your appetite (loss of or increase of)? / Yes / No
Are you having difficulty attending work or with your day-to-day activities (ex: household chores)? / Yes / No
Do you haveand/or utilize a support system (friends/family) to share your difficulties with? / Yes / No

Are you willing to be seen in the Outpatient Training Clinic by a Resident or Intern? (Non-Medicare/Non-Medicaid ONLY)

/ Yes / No
Office Use Only:
InformationGiven to: /  Elizabeth Collumb, MD /  Stephen Deutsch, MD, PhD /  Richard Handel, PhD /  Kathrin Hartmann, PhD
 Serina Neumann, PhD / Shriti Patel, MD /  David Spiegel, MD /  Maria Urbano, MD /  Outpatient Training Clinic
Accepted by: / Next available / Schedule in ______weeks

Scheduled for:

/ ______, ______at ______AM / PM
OR / Referred out to ______/ Form completed via: ______:: ______

Revised 02/2018