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Intake Assessment

Intake Assessment

Date(Required)

MM slash DD slash YYYY

Prospective Client’s Legal Name(Required)

First Last

Preferred Name

Name of person filling out form (if different) than client(Required)

First Last

Relationship to client(Required)

What was the precipitating incident that made you call today?(Required)

How did you hear about us?(Required)

Are you working with a professional?(Required)

Client Information

Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Age(Required)

Marital Status(Required)

Children/Ages (If Applicable)

Gender

Address(Required)

Street Address Address Line 2 City State ZIP Code

Can we contact the client?

Yes

No

Cell

Work

Email

Family Member Contact #1

Name

Relationship to Client

Address

Street Address Address Line 2 City State ZIP Code

Cell

Email

Home Phone

Can we contact this person?

Yes

No

Family Member Contact #2

Name

Relationship to Client

Address (If Different From Above)

Street Address Address Line 2 City State ZIP Code

Cell

Email

Home Phone

Can we contact this person?

Yes

No

Payment Information

Do you have insurance you wish to access for possible reimbursement?

Yes

No

Company

Name on Insurance Card

ID#

DOB

MM slash DD slash YYYY

Group #

Insurance Provider #

Current Environment

Are you currently employed?

Are you currently enrolled in school?

What is your current living arrangement?

What mental health symptoms is the client currently struggling with? (Check all that apply)

Anxiety

Depression

Trauma/PTSD

Mania

Grief/Loss

Executive Functioning / Lifeskills

Suicidality

Obsessive/Compulsive Behaviors

Rigidity

Anger

Hopelessness

Current Use/Substance History

Substance

Amount / Frequency

Last Use Date

Route of Administration

Withdrawal Symptoms / Cravings

Do you believe the client needs a medical detox?

Yes

No

Do you believe the client needs a psychiatric stabilization?

Yes

No

Treatment History

Prior treatments?

Yes

No

Prior treatment details

What level of care?

How long were you there?

How long did you remain clean / sober after?

Current Therapist/Counselor Name and Contact Information:

Are you willing to sign a Release of Information so that we may speak with this professional?

Yes

No

Current Psychiatrist/Medication Provider Name and Contact Information:

Are you willing to sign a Release of Information so that we may speak with this professional?

Yes

No

Medical History

Do you currently have any medical problems we need to know about?

Diabetic?

Yes

No

If yes, what was last A1C and date of test?

Please provide name and contact of any physicians currently treating you for medical conditions:

Have you been hospitalized in the past 90-days?

Yes

No

If yes, why?

Are you taking any medications?

Yes

No

Medications

Medication name

Dosage

Frequency

Reason for taking the medication

Have you lost your appetite?

Yes

No

Have you lost or gained weight recently?

Yes

No

Do you have any difficulty walking distances?

Yes

No

Trouble sleeping?

Yes

No

Memory loss?

Yes

No

Head Injuries?

Yes

No

History of Seizures?

Yes

No

Mental Health History

Have you ever been under the care of a mental health professional (therapist, psychologist, and psychiatrist)? If so, please explain:

Have you ever attempted suicide? If so, When, by what means, were you under the influence?

Have you experienced any childhood and/or adulthood trauma?

Yes

No

If yes to trauma, please explain

Have you ever harmed yourself (cutting, burning, etc.…)?

Yes

No

Have you ever had thoughts of hurting someone?

Yes

No

Do you have an eating disorder (anorexia, bulimia, over eating)?

Yes

No

Have you had any previous Mental Health Diagnosis (thought disorder, personality disorder, mood disorder)?

Yes

No

If so, please explain and include when or if current

Have you ever experienced psychosis or delusions?

Yes

No

If so, please explain and include when or if current

Were you hospitalized due to psychosis?

Yes

No

If so, for how long?

Has an injectable medication ever been recommended or prescribed?

Yes

No

If yes, did this medication require a prior authorization from your insurance?

Yes

No

Date of last injection and dosage:

Emergency Contact Information

Name

Relationship to Patient

Address

Street Address Address Line 2 City State ZIP Code

Can we contact this contact?

Yes

No

Cell

Work

Email

Thank you for taking the time to fill out this application and answer all questions! Is there anything else you think that would be helpful for us to know?

contact information

Ascend Recovery
6595 North 6000 West, American Fork, UT 84003

1 (877) 527-2363

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contact information

Ascend Recovery
6595 North 6000 West
American Fork, UT 84003

1 (877) 527-2363

Follow Us

X-twitter Instagram Facebook-f Linkedin Youtube

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