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(C) Mental Health History
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Mental Health History Form
Your full name
*
Todays Date
*
Do you consent to sharing mental health updates with your Primary Care Provider?
*
Yes
No
Current Therapist Name:
Current Therapist Phone:
Presenting Concerns
Treatment Goals
Current Symptoms (check all that apply)
*
Depressed mood
Loss of interest
Excessive worry
Anxiety/panic attacks
Racing thoughts
Impulsivity
Sleep disturbance
Fatigue
Irritability
Mood swins
Hallucinations
Suspiciousness
Concentration issues
Appetite change
Excessive energy
Risky behavior
Avoidance
Guilt
Increased libido
Decreased libido
N/A
Other
Suicide Risk Assessment
Have you had thoughts of not wanting to live?
Yes
No
Legal History
Arrest history?
*
Yes
No
Pending legal issues
Spiritual Support
Religious/spiritual affiliation?
*
Yes
No
Past Psychiatric Treatment
Outpatient treatment?
*
Yes
No
Details
Hospitalizations?
*
Yes
No
Details
Medication History
Please list any antidepressants, antipsychotics, mood stabilizers, ADHD medication, and antianxiety medications that you have previously taken. List the medications, dates, and response:
Family Psychiatric History
Family treatment history?
*
Yes
No
Please list family members and diagnosis (i.e. depression, ADHD, anxiety, Bipolar, schizophrenia, substance use) Details
Additional Information you think we should know to assist us in facilitating your personalized treatment plan.
Submit
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