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