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1. Can you please tell me what you are seeking care for?
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If Other, Please Specify
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2. What healthcare goals do you hope to achieve in seeing one of our providers?
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3. Have you ever seen a psychiatrist before?
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If YES, name & last visit
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4. Have you ever seen a therapist before?
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If YES, name & last visit
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5. Are you CURRENTLY having thoughts of harming yourself?
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If yes, do you feel the need to go to the ER or a hospital?
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If no, are you going to be able to keep yourself safe?
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6. Are you CURRENTLY having thoughts of harming others?
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7. Are you currently taking any PSYCHIATRIC medications?
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Medication/ Daily Dosage/ Frequency/ you are taking as prescribed? Medication helpful? Medication Concerns?
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8. Are any of these psychiatric medications injectables and given by needle?
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Notes related to suicidal tendencies and/or medications
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9. Have you been hospitalized and/or have been in a day treatment program (like IOP or PHP) in the last 2 years?
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If YES, how many times?
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Hospital Name/Location (City)/ Dates of Stay/ Reason for Hospitalization
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10. Have you been treated for alcohol or drug abuse in last 2 years?
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If yes, where were you treated and when?
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If yes, what substance?
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Was program completed?
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11. Have you abused any alcohol, illegal drugs or marijuana, in the past 3 months?
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If YES, which ones?
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If yes, how often?
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Every
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12. Have you been treated at a methadone clinic or received Suboxone treatment in the last two years?
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If YES, when was your last visit?
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Notes related to substance abuse
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