KHOC Mental Health Program Registration – Kitsap Homes of Compassion

Client Registration Full Legal Name Preferred Name Date of Birth Your cell phone number Your home phone number Is it OK to leave: TextVoicemailBoth Street Address City, State & zipcode Your email Preferred method of contact: Cell PhoneHome PhoneEmailOther

Emergency Contact Relationship (how do they know you?) Contact phone number

What kind of services are you interested in receiving? Check all that apply: SSI/SSDI ApplicationMental Health Case ManagementTherapy/CounselingPsychiatryMedication Management
Other:

How did you hear about us?
Intake Questionnaire
Administrative Sex: MaleFemaleOther Gender Identity: MaleFemaleTranswomanTransmanNonbinaryUnknownChoose not to discloseOther Other: Sexual Orientation: AsexualBisexualLesbian or GayStraightUnknownChoose not to discloseOther Other: Race (list all): Hispanic/Latino: NoYes If yes: Marital Status: UnmarriedMarriedDivorcedWidowedLegally SeparatedInterlocutory DecreeAnnulledSomething else/other Employment (check all that apply): Full Time EmployedPart Time EmployedSelf EmployedContract/Per DiemFull Time StudentPart Time StudentActive MilitaryRetiredLeave of AbsenceUnemployedSomething Else Religious Affiliation: NoYes If yes: Do you use nicotine products? NoYes If yes, how often?:
In the past six months, have you experienced... (check all that apply): Physical, emotional, sexual abuse, or assaultTraumatic death of someone close to youArrest, charges, or conviction of a crime (felony or misdemeanor) or spent significant time in jail or prisonSpent time, voluntary or not, in a mental health facilityMilitary deployment or military dischargeSignificant change in family status (i.e. divorce, separation, arrest, etc)Significant change in life (i.e. loss of job, loss of housing, injury, etc) Are you court involved at this time NoYes If yes, which court district?: If yes, have you been ordered to complete: Mental Health EvaluationMental Health Treatment
If yes, what is the charge(s)?: Are you a Veteran? NoYes If yes, have you ever been deployed? YesNo If yes, years active:
If yes, discharge status?:
Current Challenges (check all that apply): Generalized AnxietySpecific Fears/PhobiasPanic AttacksSocial AnxietyObsessive ThoughtsCompulsive BehaviorsBody-Focused Repetitive Behaviors (i.e. skin picking, hair pulling, nail biting, etc)Sadness or DepressionEmotionally/Mentally OverwhelmedFrequent CryingLoss of EnergyLoss of PleasureSelf Injurious/Self Harm Thoughts or BehaviorThoughts of SuicideProblems with AppetiteProblems with SleepingFatigue/TirednessNightmaresDifficult ConcentratingHearing VoicesRacing ThoughtsDifficulty Making or Keeping FriendsAngerMemory LapsesRelationship/Marriage ProblemsProblems with IntimacyProblems with JobProblems with SchoolHopelessnessHistory of Abuse (emotional, physical, sexual)Problematic Substance UseFinancial ProblemsGrief/MourningHallucinationsGuiltFeeling EmptyExcessive WorryMood SwingsCodependencyRepetitive ThoughtsLonelinessImpulsivityRestlessnessIsolation
Other: Other: Other:
Strengths - what personal qualities do you have which we can build up on in treatment? (check all that apply): Open MindedFriendlyCreativeGood listenerQuick LearnerOrganizedOrganizedTakes personal responsibilityStrong valuesIndependentAssertiveHard workerAble to learn from experience(s)Can collaborateGood problem solverGood decision makerDependableMotivated
Other: Other: Other:
Needs - What would help you achieve your treatment goals? (Please check your most important needs & prioritize your top 3): Increase my knowledge of resources that provide me with supportReferrals to resources for job training or educationAccess to medical care for health concernsStaying in a sober environmentGain more knowledge and understanding about my mental healthGet help with substance useLearn how to empower myselfIncrease effective communication skillsLearn how to talk about my concerns/issues/feelingsPractice my coping skills in a safe environmentImprove my sleepReduce anxietyUsing relaxation skillsManage my depressionLeisure skillsOrganizing daily activitiesManaging angerMood regulationImprove reality-based thinkingHealthy habits
Other:
Abilities - What skills do you possess? (check all that apply): Ability to read and writeComputer knowledge and skillsAbility to work with othersAbility to have positive relationshipsAbility to make decisions about my lifeAbility to manage time and daily activities
Job skills: Education and training: Leisure skills: Other:
Preferences - How do you want treatment? (check all that apply): Friends and Family InvolvementStructured appointmentsWeekly SessionsHomeworkMale providerFemale provider
Preferred method of learning information: VerballyHands onReadingAny
Other preferences:
Treatment History
Please provide the following information for your current and/or most recent primary care provider(s) and mental health providers including therapists and psychiatrists. Please provide as much information as you can remember. Provider Name: Clinic: Phone Number: Date(s) of Treatment
Provider Name: Clinic: Phone Number: Date(s) of Treatment
Provider Name: Clinic: Phone Number: Date(s) of Treatment

Please provide the following information for any psychiatric diagnosis you have received. Diagnosis: Diagnosis Clinician: Treatment:
Diagnosis: Diagnosis Clinician: Treatment:
Diagnosis: Diagnosis Clinician: Treatment:

Please provide the following information for any physical diagnosis you have received. Diagnosis: Diagnosis Clinician: Treatment:
Diagnosis: Diagnosis Clinician: Treatment:
Diagnosis: Diagnosis Clinician: Treatment:
Please list in chronological order all psychiatric hospitalizations or treatment center admissions. Approximate date: Length of stay: Name of hospital: Reason for admission:
Approximate date: Length of stay: Name of hospital: Reason for admission:
Approximate date: Length of stay: Name of hospital: Reason for admission:

Medication - Please list all current medications below (include prescriptions, over the counter, and herbal remedies/supplements): Name of Medication: Dosage (mg): Times a day: On for how long?: Side effects (if any): Prescribing Physician
Name of Medication: Dosage (mg): Times a day: On for how long?: Side effects (if any): Prescribing Physician
Name of Medication: Dosage (mg): Times a day: On for how long?: Side effects (if any): Prescribing Physician
Name of Medication: Dosage (mg): Times a day: On for how long?: Side effects (if any): Prescribing Physician
Name of Medication: Dosage (mg): Times a day: On for how long?: Side effects (if any): Prescribing Physician
Name of Medication: Dosage (mg): Times a day: On for how long?: Side effects (if any): Prescribing Physician
Name of Medication: Dosage (mg): Times a day: On for how long?: Side effects (if any): Prescribing Physician
Name of Medication: Dosage (mg): Times a day: On for how long?: Side effects (if any): Prescribing Physician
Name of Medication: Dosage (mg): Times a day: On for how long?: Side effects (if any): Prescribing Physician
Name of Medication: Dosage (mg): Times a day: On for how long?: Side effects (if any): Prescribing Physician

Health Habits and Personal Safety Exercise: Sedentary (no exercise)Mild exercise (i.e. routine takes stairs, walk 3 blocks, golf or other low-impact sports)Occasional vigorous exercise (i.e. sustained activity for less than 4x/wk for 30 min)Regular vigorous exercise (i.e. sustained activity for more than 4x/wk at 30min)
Caffeine: NoneCoffeeTeaPop/Soda Number of cups/cans per day
Do you drink alcohol?

Do you use tobacco or nicotine?

# of cigarette packs per day? # of cigars per day? # pipes per day? # chew per day? # noncombustibles per day (zyn, snus, etc)?
How any years? If you have quit, what year?

Do you use addictive substances?

If yes, what kind? How many times per week do you use? Are you concerned about the amount of substances you use? YesNo Have you considered stopping? YesNo

Personal Safety: Have you ever had thoughts of, planned to, or attempted suicide? YesNo If yes, when? Have you ever had thoughts of, planned to, or participated in self injury? YesNo If yes, when? Have you ever experienced domestic or intimate partner violence? YesNo If yes, when? Have you ever experienced stalking, violence, or abuse (physical or emotional) outside your home? YesNo If yes, when? Have you ever had thoughts of, planned to, or participated in violence against others? YesNo If yes, when?

Support Systems and Family History: Current Support Systems Friend GroupClose FriendsImmediate FamilyExtended FamilySpiritual GroupsRecovery Groups] Other: Other:
Childhood Experiences (check all that apply): StabilityGood gradesPopularityClose knit familyCommunity engagement (sports, activities, etc)Emotionally supported by familyFelt protected/safeFelt a sense of belongingEmotionally supported by friendsCultural engagement (traditions, heritage, etc)Good healthSupport by non-parental adultsPhysical abuseSexual abuseEmotional abusePhysical neglectEmotional neglectRacismParental/caregiver substance dependenceIncarceration of a parent/caregiverParental/caregiver separation/divorceWitnessing domestic violenceParental/caregiver mental illnessWitnessing violence outside the homeBullyingParent/caregiver deportedLiving in an unsafe areaFoster care placementHomelessness/housing instabilityLiving in a war zoneBeing an immigrantInvolvement with courtsMoving repeatedly

Family Constellation: Briefly describe your family. This would include birth family, adopted family, and/or chosen family, both immediate and extended. Name: Age: Relation to you: Relationship quality: Psychiatric history: Name: Age: Relation to you: Relationship quality: Psychiatric history: Name: Age: Relation to you: Relationship quality: Psychiatric history: Name: Age: Relation to you: Relationship quality: Psychiatric history: Name: Age: Relation to you: Relationship quality: Psychiatric history: Name: Age: Relation to you: Relationship quality: Psychiatric history:
Insurance Information: Insurance Company: Member ID: Group: Relationship to insured: SelfSpouseChildOther Insurance phone: Insured Name: Insured DOB: Insured Phone: Insured Employer: Insured Address:
Secondary Insurance Information (if applicable): Insurance Company: Member ID: Group: Relationship to insured: SelfSpouseChildOther Insurance phone: Insured Name: Insured DOB: Insured Phone: Insured Employer: Insured Address:
Any additional details about your situation: *Required* "I certify that my answers are true and complete to the best of my knowledge. My signature below indicates that I give Kitsap Homes of Compassion (KHOC) permission to release any information obtained during treatments of this patient that is necessary to support any insurance claims on this account and secure timely payments due to the assignee or myself. I understand that I am responsible for all charges, regardless of insurance coverage. In the event your account is over 120 days past due, your account may be turned over to a collection agency. I hereby assign medical benefits, including those from government-sponsored programs and other health plans, to be paid to KHOC. A photocopy of this assignment is to be considered as good as the original. Please note that clients will be asked to accept financial responsibility for payment for any scheduled appointment that is cancelled with less than 24 hour notice. "

If you are unable to complete the intake registration online, please print complete the following form on paper and return it to a KHOC staff member.

Mental-Health-Intake-Questionnai