Intake

Form

Patient Intake - Abobe Photostock

1. Intake Form

Welcome

Thank you for seeking help. We want nothing more than to get you back on your feet. During your time with us, we are here to help you in every way. To get you to the right department, please fill out the following form.

Read the form and questions through entirely before answering.

Answer the questions honestly.

We will know if you are lying.

Let’s avoid having to disect your lies.

Please print clearly. Cursive may delay care.

1. What brand of cigarettes did they put out in your arm?

2. How long could you hold your breath when he held your head in the toilet bowl?

3. Which one of the scars she gave you bothers you the most?

4. What bothered you most about your mother’s death? Was it the dementia? Or how long it took her to die?

4a. Follow up question. How long did it take for you to get bored waiting for her to die? If so, do you remember the moment when you got impatient for her to pass away?

4.c. If you don’t mind me asking: was it something internal that triggered it? an old childhood resentment, or the way she ignored you as a child? Or was it something external, perhaps the way the home health aide chewed gum, or that one Meals on Wheels driver who rubbed you wrong?

5. Tell me, which one hurt you the most, was it their they or their them? Which pronouns were used to beat you? Did one pronoun hurt worse than the other? Did one act as a safe word? For instance: did you hide when they came home, or feel safe when them walked through the door?

5a. Follow up question. When they changed their pronouns to its / your, how scared were you on a scale of one to ten? Did you feel it was your fault?

6. What lie do you still believe in? Pick from one of the following:

You deserve to be loved

You always do you’re best.

You are essential.

Thank you for reading through the form. Now that you have read everything completely, please write your full name in the upper left hand corner of the form only.

Please hand the form to the intake nurse.

A trauma addiction specialist will be with you shortly.

2. Intake

You pull the tray open, remove the wrinkled paper, and smooth it against your thigh. The toner has smudged across How long did it take for you to get bored waiting for her to die?

The folder is heavier than it looks.

Manila. Creased at the corners.

It smells faintly of toner, stale coffee, and cleaning chemicals.

You’ve been here since 6:42 a.m.

The coffee machine is broken again.

The printer blinks low cyan.

Your badge didn’t scan on the first try.

You tell yourself you’re not the gate. Just the hinge. Your wrist clicks when you open the folder.

You flip the first page.

Welcome. Thank you for seeking help. There are no…

You didn’t write that line.

You inherited it.

You tell yourself it’s clinical. Clear. Efficient.

In the waiting room, pencils move before the form gives permission.

They know what happens to blank spaces.

They unburden themselves in the margins.

You pay close attention to the handwriting. That’s what matters. The handwriting.

Block letters mean control.
All capitals mean contempt.
Illegible means attention-seeking.
Tiny letters pushed into corners mean shame.

They called it training.

There are no wrong answers.

There are patterns.

1. What brand of cigarettes did they put out in your arm?

They wrote: Marlboro Lights. My uncle liked the gold band.

You circle the brand.

You underline uncle.

You try not to picture the gold band.

Your eyes drop to your empty ring finger.

You adjust your glasses.

2. How long could you hold your breath when he held your head in the toilet bowl?

They wrote: Long enough to think about the tiles. The blurry whiteness. I counted backwards from 20. I never made it to 1.

You stop counting your own breathing.

With a red pen you write recurrent physical abuse. RPC. 1

You translate honesty into billing codes.

3. Which one of the scars she gave you bothers you the most?

They wrote: All the ones you can’t see.

The handwriting changes. The letters shrink.

4a. How long did it take for you to get bored waiting for her to die?

They wrote:

Six days. I felt guilty on the seventh. I prayed on the eighth. I googled hospice timelines on the ninth.

You press your tongue against your teeth.

You write in the margin: complicated grief. CG.1

5. Which pronouns were used to beat you?

They wrote:

They. Always they. Like a committee.

You pause

Think about your HR training.

Your continuing education credits.

Your email signature, with the optional pronouns beneath your name.

You circle nothing.

In the margin you underline committee, then erase it.

6. What lie do you still believe in?

They did not pick from the list.

They wrote: Someone will eventually fill out a form about me and understand.

It’s original, but you have to reread the line because it won’t stay in your head.

You look at the clock.

8:14 a.m.

You have nine more intakes before lunch.

There is a line at the bottom:

Please write your full name in the upper left hand corner of the form only.

They wrote it neatly.

First name. Middle initial. Last name.

You check it against their insurance card.

You check it against the chart.

You check it against the wristband.

You confirm identity before you confirm suffering.

Patients think suffering is an identity.

When you walk to the waiting room, you see them before they see you.

Leg bouncing.
Scabs on freshly healed wounds.
Hands folded too tight.
Eyes fixed on a TV that isn’t on.

You say their name.

On the desk there is a laminated script:

Maintain a neutral tone.
Avoid validation language until assessment is complete.
Do not contradict a patient’s narrative.
Do not affirm delusion.

You hate the word patient.

They are pain with paperwork.

They stand like they’ve been called to the principal’s office. The place where all the consequences live.

You smile the smile you practiced in the mirror when you started this job.

“Hi. I’ll be your intake specialist today.”

You don’t tell them you will:

Reduce their history to checkboxes.
Translate their metaphors into manageable diagnoses.
Assign them to a specialist whose calendar is already full.
Send them home with worksheets.

Later you will:

Sit in front of your home for ten minutes before walking inside.
Drink yourself to sleep.
Also lie on a form.

The door is open.

“Follow me.”

They do.

You are very good at walking slightly ahead.