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*New Intake Form

Detroit Recovery Project
1121 East McNichols Rd.
Phone 313-365-3100
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Birth Sex: 
* 
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
Identifying Information
Identifying Information:
Address:
Address Line 2:
City: State: Zip Code:
Phone: (Home)
  
(Business)
   (Cell)
Email:
Name
Preferred Name
Pronouns
Social Security Number
Date of Birth
Other Referral Source:
Referral Source:
DWIHN  
Parole or Probation Officer  
PsychologyToday  
Friends or Family  
Hospital System  
Online  
Other  
Is it ok to receive mail at this address from us?
Yes   No    
Current Residence
Address:
Address Line 2:
City: State: Zip Code:
Phone: (Home)
  
(Business)
   (Cell)
  Message may be left at above phone number?    
  Yes        No   Yes        No   Yes        No
Email:
Language
Race
Ethnicity
Veteran?
Level of education
Sexual Identity
Straight   Lesbian/gay   Pansexual  
Queer   Questioning/not sure   Asexual  
Other     
Gender Identification
Marital Status
General Status
Disabled   Employed   Refused  
Retired   Senior   Student  
Unemployed - Seeking Employment   Unemployed - Unable to Work   Other:  
Emergency contact name and phone number
GENERAL
What are the concerns that bring you here today?
Have you received assistance from us before?
Which of these programs might you fit into?
Substance Use  
Mental Health  
Outpatient Therapy  
Physical Health  
Medication Assisted Treatment  
Are you looking for:
Individual  
Intensive Outpatient  
Peer Support  
Other:  
Do you currently have a therapist? If so, name and number?
What are your previous mental health diagnoses?
Do you prefer telehealth, in-person, or either?
List any psychiatric medications you have taken in the past (name, dose, response)
Have you even been hospitalized for mental health? If so, where/when?
Do you have a history of involvement in the criminal justice system?
Have you ever made a suicide attempt? If so, method/when?
What are your main sources of emotional support?
Are you currently working?
Where are you working?
Who lives in your household?
Do you have any children? If so, ages?
Safety
Is your physical safety a problem for you right now? (such as suicidal intent or domestic violence)
No   Yes - describe:    
Risk of self-harm?
Please list any active medical problems
Are you currently taking any medications?
Yes   No    
If yes, which medications?
Are you allergic to any medications? If so, which?
Is alcohol or substance use an issue for you now?
Yes   No    
**If yes:
Substance Use    Please describe your substance use.
  Substance Date Last Used (approximately) Frequency of Use Amount Typically Used
1.
2.
3.
4.
5.
6.
Any history of withdrawal symptoms?
Yes   No   Unknown  
If so, what are the withdrawal symptoms?
Have you ever used medications for maintenance?
Yes   No    
What medication(s)?
How long ago?
Please list family members with medical diagnoses
Please list family members with mental health or substance abuse diagnoses
Do you have any family members who have had suicide attempts?
Appointment Preference Date
Appointment Preference Time
How frequently would you like to schedule your sessions?
Insured?    Does the patient have insurance?
Insurance and Financial Information
Insurance Name:
Group Number:
Policy Number:
Medicare Number:
Medicaid Number:
Do you authorize a reminder call for the day before or day of intake?
Yes   No (please explain):    
What number should we use? (If different from above)
Signature:
Signer Type:
Name:
Signature:
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Comments:
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