Title

Pre-Intake Questionnaire

This is a pre-intake questionnaire provided by Williamsville Wellness to expedite the intake process. This does not pre-qualify a patient for insurance purposes. This will expedite the intake process and assist with the initial assessment.

All fields are required unless otherwise noted

Your Name

Your Email

Your Address

Gender

Date of Birth

Phone Number (No Dashes or Parenthesis)

Weight (lbs)

Height

Marital Status
SingleMarriedDivorcedWidow/Widower

Number of Marriages

Personal - Any history of mental illness or addictions

Family - history of mental illness or addictions

Family - Living Arrangements

Current Support System, describe in as much detail as desired

Was High School Completed?
YesNo

If not, what was last grade completed?

College / University

Last Year completed or Degree Obtained

Current Work Position

Work History

Past & Current Legal Issues (Include all regardless of time frame)

Sleep per night (average estimate)
Under 3 hrs3-6 hrs6-8 hrs8+ hrs

Appetite - On average how many meals do you eat per day
NeverOnce/TwiceThreeFour/Five6+Constantly Snacking

Recent Treatment History
NoneOutpatient TreatmentPartial TreatmentResidential TreatmentDetoxHospitalizations

Recent Treatment History Details (Include when, where and how long)

Current Medications (Type, Dose & Frequency)

Addiction History

Alcohol

Type & Use

Last Use (date)

Amount of last use

Typical Frequency & Length of use

Age of first use (If never, leave blank)

Marijuana (E.G. Pot, Hashsih, Spice)

Type & Use

Last Use (date)

Amount of last use

Typical Frequency & Length of use

Age of first use (If never, leave blank)

Cocaine or Crack

Type & Use

Last Use (date)

Amount of last use

Typical Frequency & Length of use

Age of first use (If never, leave blank)

Heroin

Type & Use

Last Use (date)

Amount of last use

Typical Frequency & Length of use

Age of first use (If never, leave blank)

Opiates (E.G - Oxycontin, Percocet, Vicodin)

Type & Use

Last Use (date)

Amount of last use

Typical Frequency & Length of use

Age of first use (If never, leave blank)

Benzos (E.G. - Xanax, Valium)

Type & Use

Last Use (date)

Amount of last use

Typical Frequency & Length of use

Age of first use (If never, leave blank)

Amphetamines (E.G. - Adderall, Ritalin, Speed)

Type & Use

Last Use (date)

Amount of last use

Typical Frequency & Length of use

Age of first use (If never, leave blank)

Methampetamine

Type & Use

Last Use (date)

Amount of last use

Typical Frequency & Length of use

Age of first use (If never, leave blank)

Hallucinogens (E.G. - Mushrooms, LSD, Acid)

Type & Use

Last Use (date)

Amount of last use

Typical Frequency & Length of use

Age of first use (If never, leave blank)

Club Drugs (E.G. - MDMA, Ecstasy)

Type & Use

Last Use (date)

Amount of last use

Typical Frequency & Length of use

Age of first use (If never, leave blank)

Sleeping Pills (E.G. - Ambien, Lunesta)

Type & Use

Last Use (date)

Amount of last use

Typical Frequency & Length of use

Age of first use (If never, leave blank)

Inhalants (E.G. - Whip-its, Paint, Glue)

Type & Use

Last Use (date)

Amount of last use

Typical Frequency & Length of use

Age of first use (If never, leave blank)

Other (E.G. - Cough Syrup, Bath salts, etc)

Type & Use

Last Use (date)

Amount of last use

Typical Frequency & Length of use

Age of first use (If never, leave blank)

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