381 lines
7.7 KiB
Markdown
381 lines
7.7 KiB
Markdown
# Mental Health New Patient Intake Form
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| Form ID | FRM-MHO-001 | Revision | 1.0 |
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|---------|-------------|----------|-----|
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---
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## Patient Information
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| Field | Entry |
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|-------|-------|
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| Last Name | |
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| First Name | |
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| Preferred Name | |
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| Date of Birth | |
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| Age | |
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| Sex | ☐ Male ☐ Female ☐ Other |
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| Gender Identity | |
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| Pronouns | |
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### Contact Information
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| Field | Entry |
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|-------|-------|
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| Address | |
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| City, State, ZIP | |
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| Home Phone | |
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| Cell Phone | |
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| Email | |
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| Preferred Contact Method | ☐ Home ☐ Cell ☐ Email |
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| OK to Leave Detailed Message? | ☐ Yes ☐ No |
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## Emergency Contact
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| Field | Entry |
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|-------|-------|
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| Name | |
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| Relationship | |
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| Phone | |
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| Address | |
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## Referral Information
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| Field | Entry |
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|-------|-------|
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| Referred By | |
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| Referring Provider Phone | |
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| Primary Care Physician | |
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| PCP Phone/Fax | |
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| Current Therapist (if any) | |
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| Current Prescriber (if any) | |
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---
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## Reason for Seeking Treatment
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**What brings you in for treatment today?**
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**What are your main symptoms or concerns?**
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**When did these symptoms start?**
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**What do you hope to get out of treatment?**
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---
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## Symptom Checklist
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*Check all symptoms you are currently experiencing:*
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### Mood Symptoms
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☐ Depressed mood
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☐ Loss of interest/pleasure
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☐ Hopelessness
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☐ Guilt
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☐ Irritability
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☐ Mood swings
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☐ Elevated/euphoric mood
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☐ Decreased need for sleep
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☐ Racing thoughts
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☐ Increased energy
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### Anxiety Symptoms
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☐ Excessive worry
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☐ Restlessness
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☐ Difficulty concentrating
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☐ Muscle tension
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☐ Sleep problems
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☐ Panic attacks
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☐ Fear of social situations
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☐ Specific phobias
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☐ Obsessive thoughts
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☐ Compulsive behaviors
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### Trauma Symptoms
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☐ Flashbacks/intrusive memories
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☐ Nightmares
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☐ Avoiding reminders of trauma
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☐ Emotional numbness
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☐ Hypervigilance
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☐ Easily startled
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### Psychotic Symptoms
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☐ Hearing voices
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☐ Seeing things others don't see
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☐ Paranoid thoughts
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☐ Unusual beliefs
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☐ Confused thinking
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### Other Symptoms
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☐ Difficulty concentrating
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☐ Memory problems
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☐ Impulsivity
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☐ Anger problems
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☐ Relationship difficulties
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☐ Work/school problems
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☐ Appetite changes
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☐ Weight changes
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☐ Fatigue/low energy
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☐ Chronic pain
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## Suicidal/Self-Harm History
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| Question | Response |
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|----------|----------|
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| Are you currently having thoughts of suicide? | ☐ Yes ☐ No |
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| Are you currently having thoughts of harming yourself? | ☐ Yes ☐ No |
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| Have you ever attempted suicide? | ☐ Yes ☐ No |
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| If yes, when and how? | |
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| Have you ever engaged in self-harm (cutting, burning, etc.)? | ☐ Yes ☐ No |
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| If yes, describe: | |
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## Psychiatric History
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### Previous Treatment
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| Treatment Type | Yes/No | Where | When | Helpful? |
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|----------------|--------|-------|------|----------|
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| Outpatient therapy | ☐ | | | ☐ Yes ☐ No |
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| Outpatient psychiatry | ☐ | | | ☐ Yes ☐ No |
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| Intensive outpatient (IOP) | ☐ | | | ☐ Yes ☐ No |
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| Partial hospitalization (PHP) | ☐ | | | ☐ Yes ☐ No |
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| Psychiatric hospitalization | ☐ | | | ☐ Yes ☐ No |
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| Residential treatment | ☐ | | | ☐ Yes ☐ No |
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| ECT | ☐ | | | ☐ Yes ☐ No |
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| TMS | ☐ | | | ☐ Yes ☐ No |
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### Previous Diagnoses
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*Check all that you have been diagnosed with:*
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☐ Depression
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☐ Bipolar Disorder
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☐ Anxiety Disorder
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☐ Panic Disorder
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☐ PTSD
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☐ OCD
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☐ ADHD
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☐ Schizophrenia/Schizoaffective
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☐ Personality Disorder (type: _______)
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☐ Eating Disorder
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☐ Substance Use Disorder
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☐ Autism Spectrum Disorder
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☐ Other: _______________
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## Current Medications
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| Medication | Dose | Frequency | Prescriber |
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|------------|------|-----------|------------|
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### Past Psychiatric Medications
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*List medications you have tried in the past:*
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| Medication | Helpful? | Side Effects? | Reason Stopped |
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|------------|----------|---------------|----------------|
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| | ☐ Yes ☐ No | | |
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| | ☐ Yes ☐ No | | |
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| | ☐ Yes ☐ No | | |
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| | ☐ Yes ☐ No | | |
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## Allergies
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☐ No Known Allergies
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| Medication/Substance | Reaction |
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|---------------------|----------|
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## Substance Use History
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| Substance | Ever Used | Age First Used | Current Use | Amount/Frequency | Last Used |
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|-----------|-----------|----------------|-------------|------------------|-----------|
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| Alcohol | ☐ | | ☐ | | |
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| Marijuana/Cannabis | ☐ | | ☐ | | |
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| Cocaine/Crack | ☐ | | ☐ | | |
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| Heroin/Opioids | ☐ | | ☐ | | |
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| Methamphetamine | ☐ | | ☐ | | |
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| Benzodiazepines (non-Rx) | ☐ | | ☐ | | |
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| Tobacco/Nicotine | ☐ | | ☐ | | |
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| Other: | ☐ | | ☐ | | |
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**Have you ever had treatment for substance use?** ☐ Yes ☐ No
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If yes, describe:
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## Medical History
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### Current Medical Conditions
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☐ None
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| Condition | Notes |
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|-----------|-------|
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### Past Surgeries/Hospitalizations
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| Surgery/Hospitalization | Year |
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|------------------------|------|
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### For Women
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| Field | Entry |
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|-------|-------|
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| Are you pregnant? | ☐ Yes ☐ No ☐ Maybe |
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| Are you breastfeeding? | ☐ Yes ☐ No |
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| Last menstrual period | |
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| Using contraception? | ☐ Yes ☐ No |
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## Family Psychiatric History
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*Check all that apply to biological relatives:*
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| Condition | Mother | Father | Sibling | Grandparent | Other |
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|-----------|--------|--------|---------|-------------|-------|
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| Depression | ☐ | ☐ | ☐ | ☐ | ☐ |
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| Bipolar Disorder | ☐ | ☐ | ☐ | ☐ | ☐ |
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| Anxiety | ☐ | ☐ | ☐ | ☐ | ☐ |
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| Schizophrenia | ☐ | ☐ | ☐ | ☐ | ☐ |
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| Substance Abuse | ☐ | ☐ | ☐ | ☐ | ☐ |
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| Suicide/Attempt | ☐ | ☐ | ☐ | ☐ | ☐ |
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| ADHD | ☐ | ☐ | ☐ | ☐ | ☐ |
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| Other: | ☐ | ☐ | ☐ | ☐ | ☐ |
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## Social History
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### Living Situation
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| Field | Entry |
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| Who do you live with? | |
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| Type of housing | ☐ Own ☐ Rent ☐ With family ☐ Homeless ☐ Other |
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| Housing stability | ☐ Stable ☐ At risk ☐ Unstable |
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### Relationships
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| Field | Entry |
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|-------|-------|
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| Marital/Relationship status | ☐ Single ☐ Married ☐ Partnered ☐ Divorced ☐ Widowed |
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| Children (ages) | |
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| Quality of relationships | ☐ Good ☐ Fair ☐ Poor |
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| Social support | ☐ Strong ☐ Some ☐ Limited ☐ None |
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### Education/Employment
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| Field | Entry |
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| Highest education | |
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| Current employment | ☐ Full-time ☐ Part-time ☐ Unemployed ☐ Disabled ☐ Retired ☐ Student |
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| Occupation | |
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| Work/school problems? | ☐ Yes ☐ No |
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### Legal
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| Field | Entry |
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| Current legal issues? | ☐ Yes ☐ No |
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| If yes, describe: | |
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| History of incarceration? | ☐ Yes ☐ No |
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### Trauma History
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*Have you experienced any of the following?*
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☐ Physical abuse
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☐ Sexual abuse
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☐ Emotional/verbal abuse
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☐ Neglect
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☐ Domestic violence
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☐ Witnessed violence
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☐ Military combat
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☐ Serious accident
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☐ Natural disaster
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☐ Other trauma: _______________
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## Current Stressors
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*Rate your current stress level (1-10):* _____
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*What are your main stressors right now?*
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## Strengths and Supports
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*What are your strengths?*
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*Who are your supports (family, friends, community)?*
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*What coping strategies do you currently use?*
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## Goals for Treatment
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*What would you like to accomplish through treatment?*
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## Signature
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| Field | Entry |
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| Patient Signature | |
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| Date | |
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| Guardian Signature (if minor) | |
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| Relationship to Patient | |
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## For Office Use
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| Field | Entry |
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|-------|-------|
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| Date Received | |
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| Entered By | |
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| Appointment Date | |
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| Assigned Provider | |
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| Notes | |
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*Form FRM-MHO-001 Rev 1.0 - Mental Health New Patient Intake Form*
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