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Demographic Information
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Race / Ethnicity
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Sexual Orientation
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I chose to idenify as
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Patient Gender
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Gender Expression
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I chose to idenify as (Preferred pronoun)
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Medical History
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Current or past medical conditions (check all that apply)
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Other, Please describe
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Females of childbearing age, Are you using birth control?
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Females of childbearing age, Are you sexually active?
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Have you had surgery or have you been hospitalized?
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If yes, Please describe
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Do you have a primary care doctor?
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Primary Care Doctor
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Are you currently taking any prescribed medication?
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Please list Medication, dose, frequency, and prescriber
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Please list any allergies
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Presenting Problem
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Presenting Problem
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History of Presenting Problem
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Please rate the intensity of your problem (1 being mild 5 being severe)
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How is the problem interfering with your day-to-day functioning?
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Symptoms
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Mood
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Anxiety
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Thought Disturbance
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Symptoms Comments
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Risk Assessment
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Do you now or have you ever contemplated suicide?
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In the past few weeks, have you wished you were dead?
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In the past few weeks, have you been having thoughts of killing youself?
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In the past few weeks, have you felt that you or your family would be better off if you were dead?
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Have you ever tried to kill yourself?
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If yes, Please describe.
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Are you having thoughts of killing yourself currently?
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If yes, Please describe.
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Suicidal Ideation
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Have you been involved in violence incidents?
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If yes, What role did you play in incident ?
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In the past have you had thoughts of harming others?
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Are you currently having thoughts of harming others?
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Homicidal Ideation/Risk of Violence
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Trauma History
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Patient Experienced Trauma
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Patient Witnessed Trauma
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Trauma comments
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Psychiatric Treatment
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Have you or a family member been diagnosed with a psychiatric or mental illness?
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If yes, Please describe
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Have you taken or been prescribed antidepressants or other psychiatric medications?
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If yes, Please describe
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Have you been hospitalized for psychiatric reasons ?
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If yes, Please describe
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Are you currently participating in psychotherapy?
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If yes, Please describe
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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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Current household relationships:
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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 Concerns:
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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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Other:
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Military History
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Have you served in the military?
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If yes, What branch?
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Are you active duty?
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If no, Type of discharge
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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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Family History
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Place of Birth
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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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Relationship Status
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Do you have children?
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If yes, Please list names and ages
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Do the children current live with you?
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If no, Please explain
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Do you have family nearby?
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please describe
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Other Relevant Family Dynamics
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Other Relevant Social Relationships
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If yes, please explain:
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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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Developmental History
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Prenatal:
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Development
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Illness / Injury
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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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Substance Use History
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Do you currently use or have you used tobacco?
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Tobacco - Age at first use
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Tobacco - How often
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Tobacco-How much
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Tobacco - How administered
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Tobacco - Most recent
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Do you currently use or have you used alcohol?
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Alcohol - Age at first use
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Alcohol - How often
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Alcohol- How much
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Alcohol - How administered
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Alcohol - Most recent
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Do you currently use or have you used Marijuana?
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Marijuana - Age at first use
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Marijuana - How often
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Marijuana- How much
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Marijuana - How administered
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Marijuana - Most recent
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Do you currently use or have you used Cocaine
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Cocaine - Age at first use
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Cocaine - How often
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Cocaine- How much
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Cocaine - How administered
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Cocaine - Most recent
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Do you currently use or have you used Hallucinogens?
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Hallucinogens - Age at first use
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Hallucinogens - How often
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Hallucinogens- How much
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Hallucinogens - How administered
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Hallucinogens - Most recent
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Do you currently use or have you used Heroin?
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Heroin - Age at first use
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Heroin - How often
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Heroin- How much
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Heroin - How administered
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Heroin - Most recent
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Do you currently use or have you used Opioids
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Opioids - Age at first use
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Opioids - How often
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Opioids - How much
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Opioids - How administered
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Opioids - Most recent
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Do you currently use or have you used Meth?
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Meth - Age at first use
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Meth - How often
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Meth - How much
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Meth - How administered
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Meth - Most recent
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Do you currently use or have you used any other substances?
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Any other substances - Age at first use
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Any other substances - How often
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Any other substances - How much
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Any other substances - How administered
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Any other substances - Most recent
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Substance Abuse Treatment
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How long have you used/misused/abused drugs or other substances?
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Please discribe your substance abuse history.
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Have you received treatment for substance misuse?
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If yes, Please desrcibe when, where, and for how long.
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Have you ever overdosed?
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If yes, Please provide details ( how many times, when, on what, was it accidental or intentional):
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What was your longest period of sobriety?
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Why do you feel you relapsed?
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Mental Status Examination
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Appearance
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Personal Hygiene
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Eye Contact
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Psycho Motor Activity
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Alert and Oriented
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Behavior
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Mood
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Affect
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Speech
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Thought Content
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Attention Span
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Memory
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Insight and Judgment
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Diagnosis
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Opioid Symptoms (in the last 12 months)
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Diagnosis
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Mental Health Diagnosis (Clinicians)
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Psychological and Social Adjustments. Current Level of Functioning
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Emotional / Behavioral
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Social
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Family
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Vocational / Educational
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SUMMARY - Client issues
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Treatment Recommendations
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Other/Notes
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