Intake Form

Your story is important.

We value your unique experiences and perspectives. That's why we strive to gather culturally and informed information to better understand and support you.

First name

Last name

What name do you prefer to be called?

Birthday

Month

Day

Year

Address

Phone

What is your preferred method of communication?

Please provide your pharmacy information, which includes the name and address.

Do you require interpreter services or language assistance? If so, please describe your needs.

What is your country of origin?

What key qualities or services do you seek in a provider?

Have you used similar services in the past? If so, how was your experience?

Do you have any known allergies (ie, food, medication) or medical conditions?

Please provide brief family history of mental illness - whether diagnosed or presumed as a mental illness; this includes substance abuse history.

Have you ever been hospitalized or presented to the emergency room for mental illness? If so, please provide dates, reasons, and intervention:

Have you been prescribed any medications for mental health concerns? If yes, could you please list them? On a scale from 0 to 100, how consistently did you take your medications as directed by your healthcare provider? 0 being never and 100 being always.

Have you ever faced any form of victimization, trauma (physical, mental, or sexual), or witnessed a traumatic event in your life? Please understand that sharing is optional and your comfort and well-being are our top priority.

Are there any cultural practices or holidays that are most important for us to now about in scheduling or providing services? If so, please describe:

Are there any cultural health beliefs or practices that are important to your well-being? If so, please describe:

Are there any lifestyle considerations we should be mindful of when providing our services? If so, please describe:

How can we best accommodate your individual needs to make our services more accessible? If so, please describe:

Is there anything else you would like to share that can help us understand your preferences, values, or needs? If so, please describe

In what ways can we show respect for your cultural identity?

How important is it for you that the provider recognizes and respects your cultural background?

How would you describe your childhood and upbringing? Who raised you? Who grew up in the home where you lived? Did you feel loved and nurtured? How were you disciplined?

Please describe the network of people and resources that provide you with emotional and practical support.

Can you share some memories or characteristics that capture your personality as a child? Also, how would you describe your experiences with making friends during your childhood?

Do you have a job? If yes, could you describe your job role, your typical work hours per week, and the schedule or shift timing?

Additionally, on a scale of 0 to 10, with 0 being minimal stress and 10 being maximum stress, how would you rate the level of stress in your job?

Please describe your 1) strengths, 2) needs, 3) abilities:

Intake Form

Your story is important.

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