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Marital Status
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Seen With
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If Other
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Source of information
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Referred by
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Sleeping pattern
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Eating pattern / food issues:
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Psychiatrlc History: (lnclude treatment dates, name of provider[s], therapeutic interventions and responses)
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Psychiatric admissions
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If yes, where & dates
|
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Outpatient treatment
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If yes, where & dates
|
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Suicide attempts
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If yes, how & when
|
|
Past psych meds
|
If yes, what meds & response
|
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Family Medical & Psychiatric History: (lnclude substance abuse, hospitalizatlons, suicide attempts)
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Substance Use Past & Present: (lnclude alcohol, illicit, prescribed and OTC abuse, withdrawal sxs, blackouts)
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Longest sobriety
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|
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Psychosocial History: (School/work lssues, family history, relationships, financia!, etc)
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Legal
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Support System
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Employment status & History
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History
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|
History of abuse
• • •
|
Details
|
|
|
|
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Risk Assessment
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|
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Suicidal ideations
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Describe current plan
|
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Dates & times of past thoughts or plans
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Access to guns
|
|
Safety Plan
|
|
|
Homicidal ideations
|
Describe current plan
|
|
Dates & times of past thoughts or plans
|
Access to guns
|
|
Safety Plan
|
|
|
Other Risks or Self-harm
|
|
|
Dates & times of past thoughts or plans
|
|
|
|
|
|
Mental Status Exam
|
|
|
Anxiety
|
Hopelessness. / helplessness
|
|
Appearance
• • •
|
Motor
• • •
|
|
Speech
• • •
|
Affect
• • •
|
|
Mood
• • •
|
Judgement
• • •
|
|
Insight
• • •
|
Thought Process
• • •
|
|
Thought Content
• • •
|
If Hallucinations
|
|
Type of Hallucinations
|
If Delusions
|
|
Type of Delusions
|
Oriented
|
|
Diagnosis & Goals in treatment
|
|
|
AXIS 1
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AXIS 2
|
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AXIS 3
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AXIS 4
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AXIS 5
|
|
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Treatment Plan
|
|
