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Demographic Information
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Patient Age:
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Race / Ethnicity
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Patient Gender
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Gender Expression
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Sexual Orientation
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Marital Status
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Number of times married?
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Number of times divorced?
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Emergency contact
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Relationship to patient
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Living Arrangements
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Patient Living Arrangements
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Household Members
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Patient's Children (sex & age)
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Notes on living arrangement.
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Do your children live with you?
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If not, where?
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Educational History
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Highest Level of Education Completed
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Current Educational Setting
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Special Education
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History of Learning Problems
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Other Education Related Notes:
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Literacy Level
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Vocational History
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History of Steady Employment:
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History of Involuntary Termination
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Current Employment Status
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Vocational notes:
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What type of work do/did you do?
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How long have/did you work(ed) there?
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Legal History
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Past or Current Legal Problems
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If yes, please explain:
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Court Ordered Treatment:
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If yes, please explain:
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Other Legal History / Notes
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Have you been arrested/convicted for the following counts
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Family History
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Place of Birth
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Where was patient raised?
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Who raised patient?
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Siblings:
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List Siblings (age and gender)
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Biological Parents
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Parents Remarried
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Parents Deceased
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Relationship with Mother
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Relationship with Father
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Other Relevant Family Relationships
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Other Relevant Social Relationships
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If yes, please explain:
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Trauma History
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Patient Experienced Trauma
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Explain experienced trauma:
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Patient Witnessed Trauma
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Explain witnessed trauma:
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Family Psychiatric History
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Family History of Mental Illness
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If yes, please explain:
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Family History of Substance Abuse
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If yes, please explain:
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Family History of Completed Suicide
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If yes, please explain:
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Developmental History
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Prenatal:
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Development
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Medical History
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Illness / Injury as a Child
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If yes, please explain:
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Illness / Injury as an Adult
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If yes, please explain:
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Does patient have a Primary Care Provider?
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PCP's Name
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Does patient utilize the services of a medical specialist?
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If yes, please explain:
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Current or past medical conditions
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Please list ALL current medications
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Please list any allergies you have
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Please list any family history of illnesses
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Past Behavioral Health History
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Prior Psychiatric Treatment (mental / substance)
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If yes, please explain:
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Prior Psychiatric Diagnosis
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Other/Notes
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Are you receiving, or have you ever received counseling support?
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Substance Use History
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Have you ever attended any of the following?
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Have you ever been treated for substance missuse?
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if yes, when, where and how long for?
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Caffeine
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Age of first use
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Date of last use
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Frequency and amount
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Alcohol
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Age of first use:
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Date of last use:
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Frequency and amount:
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Tobacco
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Age of first use:
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Date of last use:
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Frequency and amount:
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Marijuana
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Age of first use:
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Date of last use:
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Frequency and amount:
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Cocaine
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Age of first use:
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Date of last use:
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Frequency and amount
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Methamphetamine
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Age of first use
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Date of last use
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Frequency and amount
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Other stimulant
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What was used
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Age of first use
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Last use, frequency and amount
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Inhalant
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Age of first use
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Date of last use
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What used, frequency and amount
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Hallucinogens
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Age of first use
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Date of last use
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What used, frequency and amount
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Oxycodone
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Age of first use
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Date of last use
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Frequency and amount
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Hydrocodone
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Age of first use
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Date of last use
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Frequency and amount
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Other Opioids
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What was used
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Age of first use
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Last use, frequency and amount
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Benzodiazepine
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Age of first use
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Date of last use
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Frequency and amount
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Other sedative/hypnotics
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What was used
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Age of first use
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Last use, frequency and amount
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Gabapentin
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Age of first use
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Date of last use
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Frequency and amount
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Other illicit use
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What was used
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Age of first use
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Last use, frequency and amount
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Heroin
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Age of first use
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Frequency and amount
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What was your longest period of abstinence?
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