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Are you a NEW patient?
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In your own words, what is the reason for seeking care at this time? Describe any current problems as you see them.
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What are your goals for therapy / what would you like to accomplish?
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Have you had any prior mental health treatment?
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Have you ever been psychiatrically hospitalized?
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Current Symptoms Checklist:
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Loss of interest
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Feel 'on edge'
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No energy
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Hyperventilation
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Cry easily
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Fainting/Dizziness
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Can't concentrate
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Pounding heart
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Can't fall asleep
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Worrying too much
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Sleep too much
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Feel hopeless
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Feel sad
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Feel Fear or Anxiety Of:
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Restless
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Nausea
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Irritable mood
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Numbness/Tingling
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Thoughts of suicide
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Chest pain
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Fidgeting
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No need for sleep
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Racing thoughts
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Fear of going crazy
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Easily distracted
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Can't pay attention
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Overactive sexually
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Interrupts others
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Feeling numb
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Uncontrollable urges
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Nightmares
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Explosive temper
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Flashbacks
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Gambling too much
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Drinking too much
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Sexually abused
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Physically abused
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Past Psychiatric Medications:
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Antidepressants
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Dates, Dosage, Response/Side Effects:
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Mood Stabilizers
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Dates, Dosage, Response/Side Effects:
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Antipsychotics/Mood Stabilizers
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Dates, Dosage, Response/Side Effects:
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Sedatives/Hypnotics
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Dates, Dosage, Response/Side Effects:
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ADHD Medications
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Dates, Dosage, Response/Side Effects:
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Antianxiety Medications
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Dates, Dosage, Response/Side Effects:
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