<p> Brock L McKay, PhD, LLC Licensed Psychologist The Therapy Center, 7807 E Funston St Wichita, Ks 67207 Phone: 316-636-1188 Fax: 316-636-1190</p><p>WELCOME, PLEASE COMPLETE THIS INITIAL INTAKE FORM</p><p>Your Name: </p><p>Today’s Date: Family Physician : Your date of birth: Age: Do you come by referral? or on your own? What brings you to this appointment? </p><p>When did this start? </p><p>Have there been periods when it has been worse? </p><p>Have there been periods where it has been better? </p><p>What are the primary symptoms that you experience? </p><p>What symptoms worry or bother you the most? </p><p>Has there been any change in frequency of symptoms? Has there been any change in symptom intensity? Has there been any change in symptom duration? What tends to make the problem better? </p><p>What tends to make the problem worse? </p><p>What might be the causing problems? Have you ever sought out treatment before? When? With whom? How was it helpful? Any previous Psychological Testing? What were the results? How would you like things to be different in 6 months? </p><p>MEDICAL HISTORY AND INFORMATION</p><p>Please list any surgeries, hospitalizations, illness, or medical problems: </p><p>Which specialists do you see currently? Are you allergic to any medicines? </p><p>Please list any allergies to substances or foods </p><p>Please list any/all medicines you are taking currently: Medicine Dosage Purpose Start Date Physician</p><p>Please list here any medicines you have taken in the past: Medicine Dosage Purpose Start Date Physician</p><p>Any job-related injuries? Any History of serious falls? ___N Y___ When? Any seizure activities? ____ N Y First onset? How treated? Losses of consciousness? _____ N Y_____ Ever had your “bell rung” in sports?______If more than one incident, please indicate the following for each incident: At what ages? What happened? Were you seen by a physician? Evaluated in the ER? Any personality or behavior changes after any of those incidents? </p><p>Any auto accidents? Was alcohol involved? Any history of electrical shocks? </p><p>Any exposure to toxic chemicals/solvents/work-place hazards? </p><p>You or anyone in the family had/have: Cancer__ Diabetes Hypertension Heart disease ______</p><p>Heart Surgery Lung/breathing problems ____ Kidney Problems Hepatitis </p><p>Stroke_ Dementia Hearing Impairment _ Head Injury______</p><p>FAMILY MEDICAL HISTORY</p><p>Any family history of the following being present on either your mother’s (put “M”) or father’s (put “F”) side of the family: Please include siblings, grandparents, aunts, uncles, cousins, nephews, nieces, offspring, etc. If any apply to you, now, or in the past, put an “S” for self.</p><p>Anxiety Panic Attacks Obsessive Compulsive Disorder ______Perfectionism _____ </p><p>Depression Manic Depression/Bipolar Suicide attempts </p><p>Psychiatric Hospitalizations Drug Use ___Alcohol problems </p><p>Post Traumatic Stress Attention Deficits ____ Hyperactivity </p><p>Driving under the influence Contact with the law Learning difficulties _____ </p><p>Problems completing school On disability Eating Disorders </p><p>Personality Problems Sexual Problems Seizures Epilepsy __</p><p>Anger problems __Significant Losses ___ Traumatic Events Breaks with reality _ </p><p>Prison Sleep Problems Divorce Extra-marital affairs </p><p>History of abuse, neglect, and/or molestation? </p><p>History of: rape and/or date rape? </p><p>Any other concerns on either side of the family? </p><p>Anything you wish to add? </p><p>BACKGROUND DATA</p><p>Where did you grow up? </p><p>What did your mother do? ___What did your father do? With whom did you live with growing up? List all members and when you lived with them. </p><p>Any serious health issues amongst your family members? </p><p>Did your parents stay together? Or divorce? </p><p>If divorced, how old were you when they divorced? </p><p>How would you describe the post-divorce time for you? </p><p>For other family members? </p><p>Do you have siblings? Ages, and whereabouts now? </p><p>With whom were you closest in the family with growing up? </p><p>And now? </p><p>How is your father’s health? </p><p>How is your mother’s health? </p><p>Did you grow up in a blended family? When did that occur? </p><p>Do you use tobacco? Type and amount? </p><p>Do you use marijuana? How often? </p><p>Did you use as a teenager? When did you first start? Last use? </p><p>How often do you drink alcohol? When did you first start? </p><p>How often do you drink to excess? </p><p>Any current drug use? </p><p>Circle any of the following you have tried in the past:</p><p>Amphetamines Cocaine Crack Ecstasy Heroin Uppers Sedatives Marijuana Mescaline Mushrooms Opium Hashish Designer drugs Cold remedies LSD Over-the-counter medicines Glues/paint/fumes/ gasoline huffing Ephedrine Muscle relaxants Anabolic Steroids </p><p>Are you sexually active? Are you content in this area? </p><p>Are you active spiritually? any formal affiliation with a religious group? </p><p>Is that a source of strength/ support for you? </p><p>On a 1-10 scale, how important is your faith to you now? Growing up? </p><p>To your family now? </p><p>To your family when you were growing up? </p><p>If there are questions not asked that you deem important about yourself, please give that information here. Also, please write below any particular questions you would like to be asked during the interview. I look forward to meeting with you. --Brock L. McKay, PhD</p>