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Presenting Problem
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Chief Complaint:
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Mental Health History
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Previous Diagnoses (if known)
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Current Symptoms
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Mood
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Sleep
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Energy
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Motivation
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Concentration/Focus
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Enjoyment in Activities
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Suicidal Ideation/Intent/Plan (current)
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Suicidal Ideation/Intent/Plan/Attempts (Past)
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Anxiety
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Panic Attacks
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Impulsive Behaviors
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Compulsive Behaviors
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Manic or Hypomanic Symptoms
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Appetite
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Recent weight loss/gain
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Eating Behaviors
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Body Image
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Brief Trauma History (if relevant)
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Current MH Treatment
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Active engagement in the following treatments
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MH Treatment History
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Brief Overview of Past Treatment Experiences
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Psychiatric Hospitalization History
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Family History of Mental Health
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Notable MH concerns in 1st degree relatives
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Substance Use
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Brief SUD information
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Need to complete full SUD assessment
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Social Developmental
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Upbringing
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Experience in School
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Family Circumstances
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Relationships with immediate family
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Primary Support
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Living Situation
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Describe current living situation
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