|
TREATMENT GOALS
|
|
|
Describe your reason for seeking care with us.
|
Why now?
|
|
What are the goals or outcomes you would like to reach with our support?
|
|
|
How will you know when you have reached these goals or outcomes?
|
|
|
What are you already doing to reach these goals or outcomes?
|
|
|
SYMPTOMS
|
|
|
Mood
|
|
|
Feel sad
• • •
|
Feel hopeless
• • •
|
|
Loss of interest
• • •
|
Nothing is fun
• • •
|
|
Are you socially isolated?
• • •
|
No energy
• • •
|
|
Thoughts of suicide
• • •
|
Disinterest in previously pleasurable activitites
• • •
|
|
Racing thoughts
• • •
|
Irritable mood
• • •
|
|
Buying/Spending Sprees
• • •
|
Guilt feelings
• • •
|
|
Explosive temper
• • •
|
Overactive sexually
• • •
|
|
Ever experienced a manic episode?
• • •
|
Ever experienced paranoia?
• • •
|
|
Have you ever heard voices or seen things that weren't there?
• • •
|
|
|
Sleep
|
|
|
Restorative Sleep
|
Sleep Rating (10 = Best, 0 = WORST)
• • •
|
|
Can't fall asleep
• • •
|
Can't stay asleep
• • •
|
|
Waking up early
• • •
|
Sleep too much
• • •
|
|
Use a CPAP device
• • •
|
Sleepwalking
• • •
|
|
Nightmares
• • •
|
No need for sleep
• • •
|
|
Anxiety
|
|
|
Flashbacks
• • •
|
Startle easily
• • •
|
|
Weight loss
• • •
|
Weight gain
• • •
|
|
Restless
• • •
|
Worrying too much
• • •
|
|
Feel 'on edge'
• • •
|
Impatient
• • •
|
|
Feel Fear or Anxiety Of:
• • •
|
Nausea
• • •
|
|
Chest pain
• • •
|
Sweating
• • •
|
|
Pounding heart
• • •
|
Numbness/Tingling
• • •
|
|
Choking sensations
• • •
|
Hyperventilation
• • •
|
|
Fainting/Dizziness
• • •
|
Dry mouth
• • •
|
|
Attention
|
|
|
Can't pay attention
• • •
|
Can't concentrate
• • •
|
|
Easily distracted
• • •
|
Can't finish tasks
• • •
|
|
Interrupts others
• • •
|
Talking too much
• • •
|
|
Fidgeting
• • •
|
|
|
Eating habits
|
|
|
Nutrition
• • •
|
Appetite
|
|
Disordered eating
• • •
|
|
|
Other
|
|
|
Gambling too much
• • •
|
Uncontrollable impulses
• • •
|
|
Very intense, unstable relationships
|
|
|
Tendency to swing between extreme over-idealizing and undervaluing people
|
|
|
Frantic actions to avoid abandonment by people who are close to me
|
|
|
Past Psychiatric History
|
|
|
Age at Onset of First Symptoms
|
When was you first treatment?
|
|
Number of episodes
|
Describe any suicide attempts
|
|
Number of hospitalizations
|
Psychotherapy
|
|
What providers do you see for mental health?
• • •
|
|
|
Medications
|
|
|
1. Medication name
|
Dosage
|
|
Why prescribed
|
How long did you take this medication?
|
|
Prescriber
|
Side Effects
|
|
Describe any benefits
|
Are you still taking this medication?
|
|
2. Medication name
|
Dosage
|
|
Why prescribed
|
How long did you take this medication?
|
|
Prescriber
|
Side Effects
|
|
Describe any benefits
|
Are you still taking this medication?
|
|
3. Medication name
|
Dosage
|
|
Why prescribed
|
How long did you take this medication?
|
|
Prescriber
|
Side Effects
|
|
Describe any benefits
|
Are you still taking this medication?
|
|
4. Medication name
|
Dosage
|
|
Why prescribed
|
How long did you take this medication?
|
|
Prescriber
|
Side Effects
|
|
Describe any benefits
|
Are you still taking this medication?
|
|
5. Medication name
|
Dosage
|
|
Why prescribed
|
How long did you take this medication?
|
|
Prescriber
|
Side Effects
|
|
Describe any benefits
|
Are you still taking this medication?
|
|
Drug and Alcohol Habits
|
|
|
Caffeine
|
Current caffeine servings per day
• • •
|
|
In the past, caffeine maximum daily servings
• • •
|
|
|
Nicotine
|
Current Nicotine Usage (Amount/ Frequency)
|
|
In the past, nicotine maximum daily use
• • •
|
Age nicotine first used
|
|
Duration of Nicotine Use
|
Last nicotine use
|
|
Comments on nicotine
|
|
|
Alcohol
|
Current Usage (Amount/ Frequency)
|
|
In the past, maximum drinks per day
• • •
|
Age alcohol first used
|
|
Duration of Alcohol Use
|
Alcohol last used (time/amt)
|
|
Comments on Alcohol use
|
|
|
Cannabis use
|
Current pattern of cannabis use
• • •
|
|
In the past, maximum cannabis use
• • •
|
Age first used
|
|
Duration of cannabis Use
|
Last cannabis use (time/amt)
|
|
Comments on cannabis use
|
|
|
Benzodiazepines
|
Current Benzo Usage (Amount/ Frequency)
|
|
In the past, maximum doses per day
• • •
|
Age first used a benzodiazepine
|
|
Duration of Benzodiazepine Use
|
Last Benzodiazepine Use (time/amt)
|
|
Comments
|
|
|
Opioids
|
Current Usage (Amount/ Frequency)
|
|
Duration of Opiate Use
|
Age first used
|
|
In the past, maximum daily opiate doses
• • •
|
Last used (time/amt)
|
|
Comments on opiate use
|
|
|
Cocaine
|
Current Cocaine Usage (Amount/ Frequency)
|
|
Duration of Use
|
Age cocaine first used
|
|
In the past, maximum cocaine use per day
• • •
|
Last used cocaine (time/amt)
|
|
Comments
|
|
|
Amphetamines
|
Current Usage (Amount/ Frequency)
|
|
In the past, maximum uses per day
• • •
|
Age Amphetamine first used
|
|
Duration of Amphetamine Use
|
|
|
Comments
|
Last used (time/amt)
|
|
Kratom
|
Current kratom use
• • •
|
|
In the past, maximum Kratom use
• • •
|
Age Kratom first used
|
|
Duration of Kratom Use
|
Kratom Last used (time/amt)
|
|
Comments
|
|
|
Psychedelics:
• • •
|
Age first used
|
|
In the past, maximum frequency of use
• • •
|
Current Usage (Amount/ Frequency)
|
|
Duration of Use
|
Last used (time/amt)
|
|
Comments
|
|
|
Pornography use
|
Current pornography use
• • •
|
|
In the past, maximum pornography use
• • •
|
Age first used
|
|
Duration of Use
|
|
|
Excessive gaming or screen time?
|
Current gaming habits
• • •
|
|
Drug of Choice
|
Adverse Consequences
|
|
Ever use intravenous drugs?
|
|
|
Have you ever felt you should cut down on using any drug or alcohol?
|
|
|
Have people annoyed you by criticizing your drug use or your drinking?
|
|
|
Have you ever felt bad or guilty about your drug use or your drinking?
|
|
|
Have you ever used substances first thing in the morning to steady your nerves (eye-opener)?
|
|
|
Total number of 'yes' responses to 4 above questions
|
|
|
Have you ever used intravenous recreational drugs?
|
|
|
Previous or Current Involvement with AA or NA?
|
If yes, sponsor
|
|
Substance treatment programs
|
Describe any legal consequences
|
|
MEDICAL INFORMATION
|
|
|
Name of your primary care provider (PCP)
|
PCP Contact Information
|
|
Past Medical History
• • •
|
Bowel problems (select all that apply)
• • •
|
|
Past Surgical History
• • •
|
Which providers do you see?
• • •
|
|
Current or past major injuries
|
Location of any chronic pain or tension
|
|
How do you describe your sex drive?
|
How do you describe your sexual orientation?
|
|
Lifestyle
|
|
|
Diet
• • •
|
Describe any mindfulness practices.
|
|
Do you exercise regularly?
|
If yes, list activities and frequencies.
|
|
3 interests/activities that support your body
|
Describe your relationship to your body.
|
|
RELATIONSHIPS
|
|
|
Briefly describe any themes or patterns in your relationships
|
|
|
If you are married or in a committed relationship, What is your Spouse's/Partner's Name?
|
|
|
How long have you been together?
|
How long have you known one another?
|
|
Do you live together?
|
Describe your friendships
|
|
How many children do you have?
|
Ages of your children
|
|
Who do you live with (Family, Friends, Roommates, Partner, Etc)?
|
|
|
Does your Spouse/Partner (Answer all that Apply)
|
|
|
Support your decision to pursue mental health care?
|
|
|
Earn an Income?
|
If yes, how?
|
|
Abuse alcohol or drugs or have any Chemical Addictions?
|
|
|
If yes, describe
|
|
|
Have a History of Psychiatric Treatment?
|
If yes, describe
|
|
EMPLOYMENT HISTORY
|
|
|
Are you Employed?
|
Present or Most Recent Employer
|
|
Occupation
|
How long have you worked in this position?
|
|
Do you enjoy what you do most of the time?
|
What are your Vocational Goals?
|
|
EDUCATIONAL HISTORY
|
|
|
Highest year of education completed
|
Field of Study
|
|
Are you currently enrolled in any classes?
|
If yes, where?
|
|
What are your Educational or Training Goals?
|
|
|
CHILDHOOD HISTORY
|
|
|
Describe your family during the time you were growing up
|
|
|
Describe your relationship with your Parents/Caregivers
|
|
|
Were you a "planned" child?
|
What do you know about your conception, intrauterine life, and birth
|
|
Did you have siblings?
|
Your birth order amongst your siblings
|
|
Number of times your family move before you turned 18
|
|
|
How did this affect you?
|
Who was your closest connection in childhood
|
|
Family history of mental illness (select all that apply):
• • •
|
|
|
Describe any major losses and/or deaths you experienced before age 18
|
|
|
Describe your feelings and impressions about your childhood
|
|
|
Family of Origin (Select all that apply)
• • •
|
|
|
Losses and Traumas
|
|
|
Any history of Physical Abuse?
|
History of Sexual Assault or Rape?
|
|
Any history of legal problems?
|
If yes, explain
|
|
Any major losses after the age of 18?
|
If yes, explain
|
|
RELIGION/SPIRITUALITY
|
|
|
Religious/Spiritual community (Past)
|
Religious/Spiritual community (Present)
|
|
If you could have a super power what would it be and why?
|
|
