Psychiatric Services Patient InformationFull NameDate of Birth MM slash DD slash YYYY AgeGenderAddressPhoneEmail Emergency ContactPhoneRelationship to Emergency ContactReferred ByPrimary Care ProviderPresenting Issue (s)Please describe the reason for your visit:How long have you been experiencing these concerns? Days Weeks Months Years Are you currently experiencing any of the following? (Check all that apply) Anxiety Depression Mood Swings Anger Issues Sleep Issues Concentration Problems Suicidal Thoughts Hallucinations Substance Use Trauma/Flashbacks Other OtherMedical & Psychiatric HistoryCurrent Medications (list name, dose, and purpose):Past psychiatric diagnoses or treatment? Yes No If yes, please explainPrevious hospitalizations for mental health concerns? Yes No If yes, when and where?Any chronic medical conditions?AllergiesFamily History Any family history of Depression Anxiety Bipolar Disorder Schizophrenia Suicide Substance Abuse Trauma/PTSD Other OtherSocial HistoryLiving Situation Alone With Partner With Family Other OtherRelationship Status Single Married Divorced Partnered Employment Status Employed Unemployed Student Retired OccupationEducation Level High School College Graduate Degree Other OtherDo you have a support system (friends/family you can talk to)? Yes No Substance Use(check all that apply) Depression Bipolar Disorder Anxiety Schizophrenia Suicide attempts/death Substance use Other Other7. Social HistoryDo you currently or have you ever usedAlcohol? Yes No Frequency FrequencyTobacco/Nicotine? Yes No Frequency FrequencyRecreational Drugs? Yes No Type/Frequency Type/FrequencyHave you ever had thoughts of harming yourself? Yes No If yes, when?Have you ever had thoughts of harming others? Yes No Any past suicide attempts? Yes No Please describe Please describeDo you feel safe at home? Yes No Goals for TreatmentWhat are some things you’d like to be different from your current situation?Signature I confirm that the above information is accurate to the best of my knowledge.SignatureDate MM slash DD slash YYYY {{#message}}{{{message}}}{{/message}}{{^message}}Your submission failed. The server responded with {{status_text}} (code {{status_code}}). Please contact the developer of this form processor to improve this message. Learn More{{/message}}{{#message}}{{{message}}}{{/message}}{{^message}}It appears your submission was successful. Even though the server responded OK, it is possible the submission was not processed. Please contact the developer of this form processor to improve this message. Learn More{{/message}}Submitting…
