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What brings you here today
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Patient Referred by:
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History - By whom
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Interim Hx
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IDENTIFYING INFORMATION
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Patient Sex
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Marital Status
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Patient arrived with
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Physical Barriers to Treatment
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CURRENT PROVIDERS
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PCP
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Specialists
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Therapists (Self)
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Other
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PAST PSYCHIATRIC HISTORY
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Patient Past Medication
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Psychiatric History Includes
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Describe
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Patient Hospitalized
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Patient Hospitalised Where
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When patient hospitalised
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Hospitalised
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Substance Abuse Treatment
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Substance Abuse Including
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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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Patient's Surgical Procedures
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Patient's Dental Provider
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Date of Last Dental Service
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Rate you risk for HIV
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Risk for STD or Hepatitis
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PATIENT FAMILY MEDICAL HISTORY
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Describe
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Family Medical History
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Describe
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FAMILY PSYCHATRIC HISTORY
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Paternal - Family Member Diagnos
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Paternal - Describe Treatment
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Maternal - Family Member Diagnos
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Maternal - Describe Treatment
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CLIENT'S DEVELOPMENTAL HISTORY
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Client's Place of Birth
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Client Raised by (Parent)
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Client's # of Siblings(Name(s)/A
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Client's Current Family Contact
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Describe
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EDUCATIONAL HISTORY
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Highest level of education
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Education History
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Vocational Schooling
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Learning Disabilities
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Special Education
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CLIENT'S SOCIAL HISTORY
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Client Marriage History
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Client's Children (names and age)
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SPIRITUAL HISTORY
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Practice by Family
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Spiritual/Cultural Belief System
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EDUCATIONAL HISTORY
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Highest level of education
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Education History
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Learning Disabilities
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Special Education
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Vocational Schooling
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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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Military - Type 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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Past Employment
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Past Employment Explain
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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 Convicted
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Ever Arrested
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TRAUMA & ABUSE HISTORY
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Sexual
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Describe
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Physical
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Describe
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Emotional
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Describe
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Neglect
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Describe
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Ever been in an accident
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Describe
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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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Do you use tobacco now
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Tobacco Amount
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Tobacco in what form
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Do you drink alcoholic beverages
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Alcoholic Beverages
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Alcoholic Beverages Amount
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Treatment for Addiction
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Describe
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Ever used prescription Med
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Do you now
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Experienced Problems With
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Explaination
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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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Marijuana - How often
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Marijuana - last use
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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 - How often
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Meth - How admin
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Amphetamines - How often
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Amphetamines - Most recent use
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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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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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Self-help groups - Al-non
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Sexually active
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Describe
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Support Systems - Family
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CRISIS & RISK ASSESSMENT
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Crisis plan necessary
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Describe
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Client's Strengths
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Clinical impression
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Prognosis
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comment
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Vocational Schooling
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Special Education
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Learning Disabilities
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Education History
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Highest level of education
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EDUCATIONAL HISTORY
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