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Patient Information

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Presenting Issue (s)

How long have you been experiencing these concerns?
Are you currently experiencing any of the following? (Check all that apply)

Medical & Psychiatric History

Past psychiatric diagnoses or treatment?
Previous hospitalizations for mental health concerns?

Family History

Any family history of

Social History

Living Situation
Relationship Status
Employment Status
Education Level
Do you have a support system (friends/family you can talk to)?

Substance Use

(check all that apply)

7. Social History

Do you currently or have you ever used
Alcohol?
Tobacco/Nicotine?
Recreational Drugs?
Have you ever had thoughts of harming yourself?
Have you ever had thoughts of harming others?
Any past suicide attempts?
Do you feel safe at home?

Goals for Treatment

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