PSYCHIATRY ADULT HISTORY FORMCJHTadmin2024-03-08T05:23:35+00:00 "*" indicates required fields First Name* First Last Name* Last Gender Date of Birth* MM slash DD slash YYYY Email Address* Phone Number*Mental Health History StatusWhat problems are you seeking help for?*Past Mental Health TreatmentHave you ever been hospitalized for psychiatric reasons?* Yes No If yes, when and where? Have you ever had outpatient treatment by a psychiatrist?* Yes No If yes, when and by whom? Have you ever received counseling or psychotherapy in the past?* Yes No If yes, when and by whom? Please List any psychiatric medication you have taken or are taking:Please List any psychiatric medication you have taken or are taking: Medications, dates, benefits & side effectsPlease check all that apply: Depressed mood Excessive talking Unreasonable fear Lost or gained weight Racing thoughts Fear of social situations Not enough sleep Easily distracted Repetitive thoughts/behavior Too much sleep Over working yourself Upsetting memories Sluggish Impulsive behavior Recent loss/grief Agitated See/hear things that are not real Work/school problems Never tired Suspect things may not be real Violent thoughts/behaviors Cannot concentrate Tense/unable to relax Self harm Afraid to leave home Excessive worry Anger outburst Inflated self esteem Panic attacks Careless, high-risk behavior Feel guilty or worthless Thoughts of death or suicide Financial problems General Medical HistoryPlease list any medical problems you may have below:Please list any serious medical procedures you have had in the past:Are you on any medications for any general medical problems you may have?* Yes No If yes, which ones? Do you have any allergies to medications?* Yes No If yes, which ones? Alcohol, Drug, and Tobacco UseDescribe your use of alcohol* Describe your use of recreational drugs:* Describe your use of tobacco:* Family Medical History List any history of illness (mental or other) and substance abuse among blood relatives:Mother’s side*Fathers’s side*Social HistoryBirth place:* Where did you grow up?* Did your parents get divorced as a child?* Yes No If so, how old were you when they separated? Father’s occupation growing up:* Mother’s occupation growing up:* How many siblings do you have?* What were your grades in grade school?* What were your grades in High School?* Did you go to College?* Yes No Do you have any children?* Yes No If so, how many? Consent to TreatmentFirst Name* First Last Name* Last We are treating you and we will do our best to accurately diagnose you and design a comprehensive treatment plan that will enable you to continue with a normal emotional development. This may include recommendations of therapy, or medications. This is all part of the service of a mental health professional. We will also work with your primary care physician to assure coordination of care.You are our client and have confidentially rights. Confidentiality does not apply under certain situation: We are obligated by law to report any suspicion of child abuse. This includes physical or sexual abuse. Also, we have a duty to protect if we suspect anyone is in danger of killing themselves or has made threats to hurt someone else.If I require or think it is in your best interest to communicate with an outside source, I will request a release of information. To assure good therapeutic care, frequent appointments are required. A new evaluation will be required for any inactive client to be seen. Considered inactive after 12 Months.I am aware that I may stop treatment with this mental health professional at any time.I am aware that if I attempt to call my my provider through phone, email, text or any other form of communication over the internet, my information may not be completely secure. In the event that my information be intercepted, this clinic is not responsible for the breach of patient privacy. Below are the approved contact means to leave messages on or respond to if contacted. DISCLAIMER By Typing Your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this document. Client Name(please Print)* Date* MM slash DD slash YYYY Signed by Client Guardian Personals Representative Client Signature*Overall, in the past 30 days, how many days were these difficulties present?* In the past 30 days, for how many days were you totally unableto carry out your usual activities or work because of any health condition?* In the past 30 days, not counting the days that you were totally unable, for how many days did you cut back or reduce your usual activities or work because of any health condition?*
