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1. What best describes the patient?
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3. What brings you in for care now?
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2. How did you hear about us?
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*Referring Clinician/Friend
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4. Is the patient currently suicidal?
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*Explanation
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7. Has the patient ever intentionally harmed self?
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*Explanation
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8. Felt physically unsafe in a relationship?
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*Explanation
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9. History of violence?
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*Explanation
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10. Experienced hallucinations?
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*Name, duration, explanation
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11. Hospitalizations for psych reason?
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Explaination
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14. Previous therapy?
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*Explanation (providers' name + duration)
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15. Previous Psychiatric care?
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*Explanation (providers' name + duration)
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16. Psychiatric or other medications?
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Name of medication(s), duration, dosage
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17. Previous or current medical condition(s)?
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name of medical condition
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22. Availability for sessions
• • •
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23. Availability specifics
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20. Anything special we need to know?
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permission to record and store CC information
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Medication History Consent
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Do you consent to text messages?
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Would you like access to our patient portal?
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Can you send us past mental health records?
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