Intake Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Full Name *Preferred Name (if any) *Email *Phone * 1. Patient Information Date of Birth (MM/DD/YYYY) *AgeGender *GenderMaleFemaleNon-BinaryOtherEmail *Home Address *Phone (copy) *Emergency Contact Name *Relationship to Patient *Emergency Contact Phone * 2. Reason for Visit Chief Complaint (in your own words)When did your concerns begin?Have symptoms changed? *WorsenedImprovedSameKnown triggers or contributing factors 3. Psychiatric History Previous mental health care? *YesNoPast psychiatric diagnoses (check all that apply) *DepressionAnxietyPTSDBipolarADHDOCDPsychotic DisorderSubstance Use DisorderOtherPsychiatric hospitalizations? *YesNoSuicidal thoughts or attempts? *NeverPastCurrentHistory of self-harm? *YesNo4. Current Symptom Checklist *Sadness / Low MoodAnxiety / WorryPanic AttacksSleep IssuesAppetite ChangesIrritabilityPoor ConcentrationHallucinationsRacing ThoughtsSuicidal ThoughtSubstance UseOther 5. Medical & Medication History Medical Conditions *Primary Care Provider *Date of last physical exam *Allergies (medications, food, etc.) *Current Medications (Name / Dose / Frequency / Prescriber) * 6. Family Mental Health History Indicate which family member (e.g. mother, uncle) Depression *Anxiety *Bipolar *Schizophrenia *Substance Use *Suicide/Attempts * 7. Substance Use Do you currently use alcohol? *YesNoDo you currently use cannabis or other substances? *YesNoPast treatment for substance use? *YesNo 8. Treatment Goals What are your treatment goals? *Any concerns about treatment? * 7. 8. When 9. Signature & Consent Patient/Guardian Signature *Date *Checkboxes *I agree with the Terms & Conditions and the Privacy & Cookies Policy of Rophe Health & Wellness Services and any applicable Terms and Conditions of Rophe Health & Wellness Services. This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.Submit