Fill and submit the form below with the correct information.

NAME(Required)

Enter Name Here

DATE OF BIRTH

AGE

Marital Status

Single

Married

Separated

Divorced

Widowed

Same Sex Partnership

Other

Gender

Male

Female

ADDRESS

PHONE NUMBER

SOCIAL SECURITY NUMBER

EMERGENCY CONTACT

PHONE NUMBER

DOES ANYONE ELSE LIVE IN THE SAME HOME WITH YOU?

Yes

NAME

AGE

RELATIONSHIP

NAME

AGE

RELATIONSHIP

NAME

AGE

RELATIONSHIP

IN YOUR OWN WORDS, PLEASE TELL US A LITTLE ABOUT WHAT HAS BEEN GOING ON THAT YOU NEED HELP WITH. I'LL COVER THE DETAILS DURING OUR FACE TO FACE VISIT SO DON'T WORRY ABOUT PUTTING EVERYTHING DOWN OR FORGETTING SOMETHING. HOW LONG HAS IT BEEN GOING ON? DID SOMETHING CAUSE IT OR MAKE IT WORSE? HOW SEVERE IS IT? DOES ANYTHING HELP YOU FEEL BETTER? IF SO, WHAT? DO YOUR SYMPTOMS COME AND GO OR ARE THEY CONSTANT? PUT DOWN ANY OTHER INFORMATION THAT YOU THINK WILL HELP ME GET TO KNOW YOU BETTER.

PAST PSYCHIATRIC HISTORY

PLEASE LIST ANY OTHER PERSON WHO HAS BEEN PROVIDING OR HAS PROVIDED MENTAL HEALTH CARE FOR YOU AND WHEN YOU WERE UNDER THEIR CARE. THIS MAY BE ANOTHER PSYCHIATRIST, A PSYCHOLOGIST, SOCIAL WORKER, SCHOOL COUNSELOR, INDIVIDUAL THERAPIST, MARITAL THERAPIST, MINISTER, PRIEST OR PASTORAL COUNSELOR. YOU SHOULD INCLUDE ANYONE WHO HAS PRESCRIBED PSYCHIATRIC MEDICATION FOR YOU (PRIMARY CARE PROVIDER, OBGYN, FAMILY NURSE PRACTITIONER, OTHER HEALTH CARE PROVIDER.

PROVIDER

WHEN SEEN

MM slash DD slash YYYY

PROVIDER

WHEN SEEN

MM slash DD slash YYYY

PROVIDER

WHEN SEEN

MM slash DD slash YYYY

LIST ALL CURRENT MEDICATIONS, DOSAGE, INSTRUCTIONS, WHO PRESCRIBES THEM AND WHAT YOU TAKE THEM FOR:

MEDICATION/DOSE

INSTRUCTIONS

CONDITION TREATED

PRESCRIBE

MEDICATION/DOSE

INSTRUCTIONS

CONDITION TREATED

PRESCRIBE

MEDICATION/DOSE

INSTRUCTIONS

CONDITION TREATED

PRESCRIBE

HAVE YOU EVER ATTEMPTED SUICIDE?

Yes

PLEASE DESCRIBE BELOW

HAVE YOU EVER BEEN PSYCHIATRICLY HOSPITALIZED?

Yes

WHERE?

WHEN

MM slash DD slash YYYY

IF YOU HAVE BEEN ON OTHER PSYCHIATRIC MEDICATION IN THE PAST PLEASE LIST THEM HERE

ALCOHOL AND DRUG HISTORY

ALCOHOL USE

None

Rarely

Sometimes

Often

IF YOU DRINK AT ALL, WHAT ALCOHOL CONTAINING BEVERAGE/S DO YOU USUALLY DRINK?

HOW LONG AGO WAS THE LAST TIME YOU HAD A DRINK?

Untitled

I have tried to cut back on my drinking.

I have become angered or annoyed by others criticizing my drinking.

I feel guilty about my drinking.

I have gotten up in the morning and had a drink to steady my nerves.

Alcohol

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

MARIJUANA

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

COCAINE

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

CRYSTAL METH

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

ICE

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

ADDERALL

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

VYVANSE

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

RITALIN

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

LSD

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

XTC/MOLLY

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

PEYOTE

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

KETAMINE

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

MUSHROOMS

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

XANAX

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

VALIUM

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

KLONOPIN

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

ATIVAN

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

DEXTROMETHORPHAN

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

STEROIDS

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

SPICE

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

BATH SALTS

AGE AT FIRST USE

HOW MUCH USED HOW OFTEN

LAST USED

ON AVERAGE HOW MUCH DO YOU SPEND PER WEEK ON ALCOHOL AND/OR DRUGS?

PLEASE LIST PLACES WHERE YOU HAVE BEEN TREATED FOR ALCOHOL OR DRUG-RELATED PROBLEMS BELOW:

FACILITY

WHEN

MM slash DD slash YYYY

FOR WHAT

TREATMENT

Finished treatment

Left early

FACILITY

WHEN

MM slash DD slash YYYY

FOR WHAT

TREATMENT

Finished treatment

Left early

FACILITY

WHEN

MM slash DD slash YYYY

FOR WHAT

TREATMENT

Finished treatment

Left early

HAVE YOU EVER PARTICIPATED IN 12-STEP RECOVERY (AA/NA)?

Yes

DO YOU CURRENTLY PARTICIPATE IN 12-STEP RECOVERY?

Yes

PAST MEDICAL HISTORY

LIST MEDICAL PROBLEMS BELOW

PAST SURGICAL HISTORY

LIST ALL SURGERIES BELOW

ALLERGIES

FAMILY HISTORY

PLEASE LIST RELATIVES WITH MENTAL ILLNESS, CHEMICAL DEPENDENCY OR COMPLETED SUICIDE HERE

PLEASE LIST RELATIVES WITH OTHER ILLNESSES HERE

PSYCHOSOCIAL HISTORY

WHERE WERE YOU BORN?

WHERE DID YOU GROW UP?

WHO RAISED YOU?

HOW MANY BROTHERS AND SISTERS DID YOU HAVE?

WHAT WAS YOUR CHILDHOOD LIKE?

DID ANYONE EVER PHYSICALLY ABUSE YOU?

Yes

WHO?

DID ANYONE EVER EMOTIONALLY ABUSE YOU?

Yes

WHO?

DID ANYONE EVER SEXUALLY ABUSE YOU?

Yes

WHO?

WHAT IS YOUR HIGHEST LEVEL OF EDUCATION?

Yes

WHO?

ARE YOU EMPLOYED?

Yes

WHAT DO YOU DO?

DID YOU EVER WORK?

Yes

WHAT JOBS DID YOU HAVE IN THE PAST?

ARE YOU MEDICALLY DISABLED?

Yes

FOR WHAT REASON?

HOW MANY TIMES HAVE YOU BEEN MARRIED?

LIST ALL MARRIAGES, HOW LONG THEY LASTED AND IF THEY ENDED WHAT THE REASON WAS

HOW MANY CHILDREN DO YOU HAVE? PLEASE LIST ALL CHILDREN AND FROM WHAT RELATIONSHIP THEY ARE FROM

WHAT IS YOUR SEXUAL PREFERENCE?

Heterosexual

Bisexual

Homosexual

PLEASE BRIEFLY EXPLAIN

ARE YOU CURRENTLY ON PROBATION?

ARE YOU CURRENTLY INVOLVED IN A LAWSUIT?

Yes

PLEASE BRIEFLY EXPLAIN

WHAT RELIGION ARE YOU?

ARE THERE ANY OTHER THINGS THAT WOULD BE HELPFUL TO KNOW ABOUT YOU THAT WERE NOT COVERED ALREADY?

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PLEASE LIST PLACES WHERE YOU HAVE BEEN TREATED FOR ALCOHOL OR DRUG-RELATED PROBLEMS BELOW:

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