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Which of the following services/treatments are you interested in receiving?
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Please describe how you found out about our clinic. Please be as specific as possible.
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Which clinic location are you interested in being seen at?
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SOCIAL HISTORY
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What is your relationship status?
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Please describe your current living situation.
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Do you have children?
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Please list your childrens names, ages, and gender.
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Are you currently working?
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Please describe your current occupation, or lack thereof:
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Are you currently a student?
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Please describe your current student status (if applicable), such as, what school, what degree program etc.
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What is your highest level of education completed?
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How do you describe your social network?
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How often do you make contact with your social network?
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How often do you exercise?
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How do you describe your diet?
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How is your general health?
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SUBSTANCE USE HISTORY
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Do you smoke tobacco or use any tobacco products?
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Please describe your current and/or previous tobacco use history here (if applicable).
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Do you drink alcohol currently?
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Do you have a history of problems with alcohol?
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Please describe your current and/or previous alcohol use history here (if applicable).
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Do you current use any illicit drugs?
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Do you have a history of illicit substance use?
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Please describe your current and/or previous illicit substance use history here (if applicable).
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MEDICAL AND PSYCHIATRIC HISTORY
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Please list your current psychiatric medications here (please list name, dosage, and start date):
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Please list your current non-psychiatric medications here (please list name, dosage, and start date):
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Do you take any supplements, vitamins, over-the-counter products?
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Please list any OTC, supplements, vitamins, etc.
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Please list all previous psychiatric medications here (names, start/stop dates, reason for stopping, effectiveness, etc.)
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Do you currently have a Primary Care Physician?
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List your PCM's name and his/her contact info here (if you have it).
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Do you currently have a psychiatrist?
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List your psychiatrist's name and his/her contact info here (if you have it).
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Do you currently have a therapist?
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List your therapist's name and his/her contact info here (if you have it).
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Have you ever been hospitalized for psychiatric or substance abuse problems?
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Please list dates, hospital names, and reasons for psychiatric and/or substance abuse hospitalizations here:
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Have you ever been hospitalized for any medical conditions/problems?
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Please list dates, hospital names, and reasons for psychiatric and/or substance abuse hospitalizations here:
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Please list any major illnesses or accidents in the past 5 years (if applicable) here:
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Please list any existing medical problems or physical symptoms that are of concern to you:
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FAMILY PSYCHIATRIC HISTORY
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Have any of your close blood relatives had any history of major mental illness or substance use problems?
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Please describe your family history of mental illness and/or substance misuse here:
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Patient Health Questionnaire-9
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Over the last 2 weeks, how often have you been bothered by any of the following problems?
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1) Little interest or pleasure in doing things
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2) Feeling down, depressed, or hopeless
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3) Trouble falling or staying asleep, or sleeping too much
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4) Feeling tired or having little energy
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5) Poor appetite or overeating
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6) Feeling bad about yourself - or that you are a failure or have let yourself or your family down
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7) Trouble concentrating on things, such as reading the newspaper or watching television
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8) Moving or speaking so slowly, or more fidgety/restless than usual, so that other people could have noticed?
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9) Thought that you would be better off dead, or of hurting yourself in some way
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How difficult have these problems made it for you to do your work, take care of things at home, or get along with people?
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