Date:*
Patient Name:*
Patient DOB:*
Home Address:*
Phone Number:*
Email:*
Referred by:
Insurance Company Name:*
Policy ID number:
Group number:
State the reason for today appointment:*
How long has this been an issue?*
Please list the ways you have attempted to alleviate the issue so far:*
Please name the people who reside in your home (Include relationship and age):
Who raised you?
Number of siblings?
How would you describe your relationship with your family of origin? ExcellentGoodFairPoor
Did you suffer abuse as a child? YesNo
If so, what kind? SexualNeglectPhysical
Please describe:
Has anyone in your family been diagnosed with a mental health issue? Please list the family member(s) and the diagnosis below:
What are the three biggest stressors in your life?
What is your highest level of education?
Are you currently working? YesNo
What is your occupation?
Describe your marital status: SingleMarriedSeparatedDivorcedWidow
Are you in a committed relationship at this time? YesNo
If yes, how long?
Are you happy in your relationship? YesNo
Have you ever been arrested? YesNo
If yes, describe:
Have you ever served time for a criminal conviction? YesNo
Have you ever been involved in legal proceedings for any reason other than an arrest? YesNo
Do you have a current or previous health issue that affects you daily? YesNo
If yes, provide details:
Current medications and dosage (include vitamins and supplements):
List previous psychiatric/behavioral health providers (inpatient and outpatient):
Have you ever attempted suicide? YesNo
If yes, please describe:
Are you currently having suicidal thoughts? YesNo
If yes, please describe the thoughts:
My mood is usually (check all that apply): HappySadTenseUnstableAngry
Current Symptoms(check all that apply): Sleep disturbanceAnxiety/WorrySadnessPhobiaAppetite changesChange in sex driveSocial isolationHopelessnessPoor concentrationPoor motivationTrouble making decisionsLow self esteemFatigue/Lack of energyFidgetyLoss of interest in preferred activitiesVisual HallucinationsAuditory HallucinationsEmotional eatingAnger/IrritabilityPoor body image
List symptoms not listed above:
Have you ever been treated for a substance abuse issue? YesNo
By checking the box, I agree that the above information is accurate and true.
