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Demographic Information
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Race / Ethnicity
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Marital Status
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Patient Gender
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Gender Expression
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Sexual Orientation
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Presenting Problem
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History of Presenting Problem
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Patient Strengths
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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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Suicidal Ideation
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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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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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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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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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What substances have you used?
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Tobacco - Age at first use
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Tobacco - How often
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Tobacco - How administered
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Tobacco - Most recent
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Alcohol - Age at first use
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Alcohol - How often
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Alcohol - How administered
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Alcohol - Most recent
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Marijuana - Age at first use
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Marijuana - How often
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Marijuana - How administered
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Marijuana - Most recent
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Cocaine - Age at first use
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Cocaine - How often
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Cocaine - How administered
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Cocaine - Most recent
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Hallucinogens - Age at first use
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Hallucinogens - How often
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Hallucinogens - How administered
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Hallucinogens - Most recent
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Heroine - Age at first use
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Heroine - How often
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Heroine - How administered
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Heroine - Most recent
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Opioids - Age at first use
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Opioids - How often
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Opioids - How administered
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Opioids - Most recent
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Meth - Age at first use
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Meth - How often
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Meth - How administered
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Meth - Most recent
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Other prescription drugs - Age at first use
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Other prescription drugs - How often
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Other prescription drugs - How administered
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Other prescription drugs - Most recent
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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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Other/Notes
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SUMMARY - Client issues
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SUMMARY - Recommendations
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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
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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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