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IDENTIFYING INFORMATION
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Patient Sex
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Sexual Hx
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Comments
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Referral Source:
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Marital Status
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Client's Divorce Hx
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General Relationship Comments
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Patient arrived with
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Accompanied (By Whom)
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Living Arrangements
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Patient lives with whom explain (other than above)
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Patient Employment Status
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School Attending:
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Occupation Select
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Occupation
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Physical Barriers to Treatment
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Physical Barriers Comments
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Specific Barriers to Treatment
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Specific Barriers Others
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CURRENT PROVIDERS
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PCP
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Specialists
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Current Therapist:
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Other
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PAST PSYCHIATRIC HISTORY
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Psychiatric History Includes
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Patient Hospitalized in Past:
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Past Psychiatric Hospitlizations:
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When patient hospitalised
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Patient Hospitalized Where
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Hospitalized
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Past Mental Health Treatment:
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Other Previous Treatment
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Past Mental Health Problems:
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Other past mental health problems:
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Past Medications Used:
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Other Past Medications:
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CLIENT'S MEDICAL HISTORY
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Medical/Physical Problems
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Any other medical problem
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Surgical History:
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Other Surgical History:
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Immunizations
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Comments
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Childhood illnesses
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Comments
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Recent Tests, Labs
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OB & Pregnancy Hx
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Abortions
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Miscarriages
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PATIENT FAMILY HISTORY
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Family History Unknown
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Mother's MH
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Comments
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Father's MH
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Comments
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Sibling(s)' MH
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Comments
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Grandparent's MH
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Comments
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Children(s)' MH
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Comments
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Other Family History:
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Comments
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Other Family Medical & Mental Health History:
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CLIENT'S DEVELOPMENTAL HISTORY
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Denies Psych Family History
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Client's Pregnancy
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Client's Place of Birth
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Client's Family Biological/Adopt
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Client Adopted Age
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Client's # of Moves in Lifetime
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Development
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Development Explain
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Client's Parents Married
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Client Raised by (Parent)
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Client's # of Siblings(Name(s)/A
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Siblings (Name(s) and Age(s)
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Client's Family Contact
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Grade Completed
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School Performance
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Temperment
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Friends
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Abuse/Neglect
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Conduct Symptoms
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Behavioral Discipline At School
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Client First Sexual Encounter Ag
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Was this consensual
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Sexual Orientation(s)
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Sexually Active?
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SPIRITUAL HISTORY
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Preferred Religion:
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Practice by Family
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Spiritual/Cultural Belief System
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Spiritual/Cultural Comments
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CLIENT'S HISTORY
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Client Marriage History
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Client's Children (names/ages):
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EDUCATIONAL HISTORY
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Last School Attended
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Learning Disabilities
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Learning Disabilities Comments
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Special Education
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Special Education Comments
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College Training
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College Training Where
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Vocational Schooling
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Vocational Schooling Where
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Special Training
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Special Training Where
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MILITARY SERVICE
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Military Service
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Military Service Branch
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Military Service Active Duty
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Combat/Deployment History:
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Military - Type of Discharge
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Military - Date of Discharge
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VOCATIONAL HISTORY
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Vocational History
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Current Employment
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Current Employment Explain
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Current Employment Duration
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Past Employment
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Past Employment Explain
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Past Employment Duration
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Reason for Leaving
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LEGAL HISTORY (Explain if Necess
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Current Legal Problems
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Ever Arrested
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Ever Convicted
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Reasons for Incarceration:
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Longest Period of Incarceration:
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Drug Court
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Probation Officer & Number
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Incarcerations, Location, Length
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Violence History
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TRAUMA & ABUSE HISTORY
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Sexual
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Age when abuse started:
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Describe- Nature of Relationship
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Describe - Duration
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Describe - Severity of Abuse
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Physical
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Age when abuse started:
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Describe- Nature of Relationship
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Describe - Duration
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Describe - Severity of Abuse
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Emotional
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Age when abuse started:
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Describe- Nature of Relationship
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Describe - Duration
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Describe - Severity of Abuse
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Neglect
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Age when neglect started:
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Describe- Nature of Relationship
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Describe - Duration
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Describe - Severity of Abuse
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Ever been in an accident
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Seen someone injured or die
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Die or Injured Comments
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SUBSTANCE USE HISTORY
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Have you ever used tobacco
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Age at first use:
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Do you use tobacco now
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Tobacco Amount
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Tobacco Other Amount
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Tobacco Form Used:
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Tobacco other form:
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Do you have a history of alcohol use?
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Age at first use:
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Do you currently drink alcoholic beverages
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Alcohol Use Frequency:
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Alcoholic Beverages
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Alcoholic Beverages Amount
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AUDIT SCORE
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Do you drink caffeine beverages
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Caffeine Amount Daily
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Treatment for Addiction
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Drug/Alcohol Abuse Treatment
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Ever used street drugs
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Ever used prescription Med
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Do you use any street drugs now?
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Rate you risk for HIV
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Risk for STD or Hepatitis
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Experienced Problems With
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Explain Experienced Problems
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SUBSTANCE USE INFORMATION
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Drug - Age at first use
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Drug - Most recent use
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Drug - How often
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Drug - How Admin
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Caffeine - How often
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Marijuana - Age at first use
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Marijuana - Most recent use
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Marijuana - How often
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Marijuana - How admin
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Cocaine/Crack - Age at first use
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Cocaine/Crack - Most recent use
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Cocaine/Crack - How often
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Cocaine/Crack - How admin
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Hallucinogen - Age at first use
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Hallucinogen - Most recent use
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Hallucinogen - How often
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Hallucinogen - How admin
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Heroin - Age at first use
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Heroin - Most recent use
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Heroin - How often
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Heroin - How admin
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Opioids - Age at first use
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Opioids - Most recent use
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Opioids - How often
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Opioids - How admin
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Meth - Age at first use
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Meth - Most recent use
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Meth - How often
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Meth - How admin
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Methamphetamines- Age-first use
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Methamphetamines-Most recent use
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Methamphetamines- How often
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Methamphetamines- How admin
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Amphetamines - Age at first use
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Amphetamines - Most recent use
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Amphetamines - How often
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Amphetamines - How admin
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Prescription meds- Age-first use
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Prescription med-Most recent use
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Prescription meds - How often
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Prescription meds - How admin
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Nicotine - Age at first use
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Nicotine - Most recent use
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Nicotine - How often
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Nicotine - How admin
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Other Abuse Comments
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Substance Abuse Treatment
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Substance Abuse Including
• • •
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Reactions to Treatment Received
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Experience with self-help groups
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Self-help groups - AA
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Self-help groups - NA
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