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1. Your Name:
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2. Today's Date:
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3. Date of Birth:
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4. What bring you to seek care with me at this time?
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5. Are you seeking a medication evaluation, therapy, or both?
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6. What goals do you have for this treatment?
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7. What current symptoms are you experiencing? (Select all that apply)
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8. Have you experienced trauma?
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9. Have you seen a mental health provider(s) previously?
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10. If yes, please include the following information: Name of provider, time period, reason for changing:
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11. Do you have a current therapist, counselor, or psychiatric provider? If yes, what is their name?
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12. Have you previously received a diagnosis from a mental health provider?
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13. If yes, what were you diagnosed with?
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14. What current and past psychiatric medications have you taken? Please list All current and past prescription medications
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15. Please describe any side effects or adverse effects you have experienced with medication(s):
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16. Family Psychiatric history: Has anyone in your family ever experienced any of the following?
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17. If yes, who had each problem:
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18. Has a family members ever been treated with a psychiatric medication? If so, which medication and how effective?
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19. Have you ever misused or taken a prescription medication other than as prescribed?
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20. Have you ever been treated for any substance misuse? If so, please describe (setting, dates or treatment, outcome)
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21. How much caffeine do you ingest daily?
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22. Do you drink alcohol? If so, how many occasions per week and how many drinks per occasion?
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23. Do you use nicotine in any form (cigarettes, cigars, pipe, chewing tobacco, vape, nicotine patch or gum)?
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24. Do you use any other substances?
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25. Have you ever been admitted to a psychiatric hospital, and if so, why?
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26. Have you ever attended an Intensive Outpatient or Partial Hospital Program? If so, when and where?
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27. Do you have aby religious or spiritual preferences or practices that you would like to mention?
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