IOP Mental Health Call Now(240) 896-5159 "*" indicates required fields NameThis field is for validation purposes and should be left unchanged.Date of Intake* MM slash DD slash YYYY Initial Screening Completed By* Table of Contents Toggle Personal InformationReferral InformationVitalsUrine Drug Screen (UDS)Mental Health HistoryMedical Health HistoryHousing StatusEmployment StatusEducationFamily and Social HistoryLegal HistoryStrength and GoalsGeneral Health StatusPain Assessment ToolNutrition AssessmentSuicide ScreeningIf the patient answers yes to any of the above, ask the following question: Personal InformationFull Name*Date of Birth* MM slash DD slash YYYY Social Security*Gender*MaleFemaleRace*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone Number*Email* Emergency Contact Name*Relation*Number*Email* Referral InformationReferred By (if applicable)Contact Information of ReferrerReason for ReferralVitalsBlood PressureHeightPulse OxHearth RateWeightUrine Drug Screen (UDS)DetailsMental Health HistoryHave you ever been diagnosed with a mental health condition? Yes No If yes, when and where?Current Symptoms (check all that apply) Depression Anxiety Mood Swings Hallucinations Suicidal Thoughts Anger/Irritability Poor Concentration Impulsivity Self-Harming Behaviors Do you believe your mental health has contributed to past substance use or relapses? Yes No If yes, please explain?Current Psychiatric MedicationsPrescribing ProviderDate of Last Psychiatric EvaluationHave you ever been hospitalized for mental health? Yes No If yes, when and where?Medical Health HistoryPrimary Care PhysicianLast physical ExamDo you need a referral to see a physician for a physical?Do you have any current medical conditions? Yes No If yes, please list?Current MedicationsAllergiesHousing StatusLiving SituationHomelessLiving with Family/FriendsOwn/Rent HousingOther (please specify)Other living situationEmployment StatusAre you currently employed? Yes No If yes, what type of job?If yes, what is your schedule?Education Highest Level of Education AchievedAre you currently in school? Yes No If yes, where?Family and Social HistoryDescribe your current family dynamicDo you have a support system? Yes No If yes, who?Have you experienced trauma or abuse? Yes No If yes, please explain brieflyAre you currently in a relationship? Yes No If yes, (check all that apply) Supportive Stressful Involved in Substance Use Abusive Other OtherDo you have children? Yes No Are you the primary caretaker? Yes No Legal HistoryDo you have a history of arrests or incarceration? Yes No If yes, please explainAre you currently on probation or parole? Yes No Probation/Parole Officer Name & PhoneStrength and GoalsList 3 personal strengthsWhat are your goals for treatment?What do you hope to achieve by participating in services?General Health Status1. How would you rate your overall physical health? Excellent Good Fair Poor Please explain Please explain2. How motivated are you to improve or manage your physical health? Not at all Somewhat motivated Moderately motivated Very motivated 3. Do you have any current medical conditions? Yes No If yes, please list all diagnosed conditions4. Have you had any recent hospitalizations, surgeries, or ER visits? Yes No If yes, provide dates and reasons5. Do you experience any of the following on a regular basis? (Check all that apply) Chronic pain Headaches or migraines Breathing difficulties Heart issues Seizures Gastrointestinal issues Fatigue or weakness Other Other6. Do you have any disabilities or chronic illnesses that affect your daily functioning? Yes No If yes, please explain7. Do you have difficulty remembering things or making decisions? Yes No 8. Do you have any developmental disabilities or history of brain injury? Yes No If yes, please describe9. Do you require any of the following to assist with mobility or care? Wheelchair or walker Personal care assistant Home health nurse Medical equipment (e.g., oxygen, CPAP) Other Other10. Do you have any untreated or undiagnosed physical health symptoms or conditions that you are concerned about? Yes No If yes, describePain Assessment Tool Pain locationPain locationHeadNeckShouldersArmsHandsGroinHipsLegsFootPain is worseMorningAfternoonEveningNightPatient Description of Pain- Check all that apply Sharp Dull Ache Tingles Stings Tender Throbbing Burning Other OtherUntitled Does the pain radiate? Patient Unable to describe/respond Pain Rating ScoreNutrition AssessmentFood Allergies (Confirmed or suspected) Please listHave you lost or gain 10 pounds or more in the last 3 months?YesNoHow much?Do you have a decrease in food intake and/or appetite?YesNoDo you have any Dental problems?YesNoEating habits or behaviors that may be indicators of an eating disorder,BingeingInducing vomitingPurging (use laxatives frequently)Do you avoid family dinners and social events involving food?Suicide Screening1. In the past few weeks, have you wished you were dead? Yes No 2. In the past few weeks, have you felt that you or your family would be better off if you were dead? Yes No 3. In the past week, have you been having thoughts about killing yourself? Yes No 4. Have you ever tried to kill yourself? Yes No If yes, how?When?If the patient answers yes to any of the above, ask the following question: Are you having thoughts of killing yourself right now? Yes No Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?
