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adult history form

Please fill out the form below.

Mental Health History Status
Past Mental Health Treatment
Have you ever been hospitalized for psychiatric reasons?
Have you ever had outpatient treatment by a psychiatrist?
Have you ever received counseling or psychotherapy in the past?
Please List any psychiatric medication you have taken or are taking:
Please check all that apply:
General Medical History
Are you on any medications for any general medical problems you may have?
Do you have any allergies to medications?
Alcohol, Drug, and Tobacco Use
Family Medical History
List any history of illness (mental or other) and substance abuse among blood relatives:
Social History
Did your parents get divorced as a child?
Did you go to College?
Do you have any children?
Consent to Treatment
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 madethreats 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.  
This questionnaire asks about difficulties due to health conditions. Health conditions include diseases or illnesses, other health problems that may be short or long lasting, injuries, mental or emotional problems, and problems with alcohol or drugs.

Think back over the past 30 days and answer these questions, thinking about how much difficulty you had doing the following activities. For each question, please circle only one response.

In the past 30 days, how much difficulty did you have in:

1. Standing for long periods such as 30 minutes?
2. Taking care of your household responsibilities?
3. Learning a new task, for example, learning how to get to a new place?
4. How much of a problem did you have joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can?
5. How much have you been emotionally affected by your health problems?
6. Concentrating on doing something for ten minutes?
7. Walking a long distance such as a kilometre [or equivalent]?
8. Washing your whole body?
9. Getting dressed?
10. Dealing with people you do not know?
11. Maintaining a friendship?
12. Your day-to-day work?
Patient Health Questionnaire

Over the last two weeks, how often have you been bothered by the following problems?

1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself or that you are a failure orhave let yourself or your family down
7. Trouble concentrating on things, such as reading thenewspaper or watching television
8. Moving or speaking so slowly that other people couldhave noticed. Or the opposite being so figety orrestless that you have been moving around a lot morethan usual
9. Thoughts that you would be better off dead, or ofhurting yourself
If you checked any problems, how difficult have they made it for you to do your work, take care of things at home, or get along with other people?
GAD-7 Anxiety

Over the last two weeks, how often have you been bothered by the following problems?

1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritabl
7. Feeling afraid, as if something awful might happen
If you checked any problems, how difficult have they made it for you to do your work, take care of things at home, or get along with other people?

Thanks for submitting!

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