PSYCHIATRIC INTAKE AND TREATMENT PLAN-PART I TO BE FILLED BY PATIENT PLEASE PRINT

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Transcription:

DOB: / / / PSYCHIATRIC INTAKE AND TREATMENT PLAN-PART I TO BE FILLED BY PATIENT PLEASE PRINT Date Age Gender M F Current address: Married. Single Separated Divorced Widowed If patient is a child, he/she live with: Biological parent Stepmom Stepdad Other: How did you hear about our services? In the PAST TWO WEEKS have you experienced any of the following: (Check All That Applies) Depression changes in your appetite sleep disturbance fatigue low self esteem thoughts of suicide getting into fights wishing you were dead manic episodes increased energy (even when not sleeping) racing thoughts panic attacks anxiety irritability muscle tension obsessions (intrusive repetitive thoughts) specific fears or phobias compulsions (repetitive acts that are unreasonable) anger forgetfulness easily distracted impulsivity hallucinations paranoia homicide thoughts mood swings Other Problems that are not listed above: When did the problem start? Have you ever witnessed or experienced a traumatic event that involved death or serious injury? No Yes Any history of violence? Against Property Against People Only Thoughts of Please list all of your current medications including over the counter pills: Medication Duration Dosage Medication Duration Dosage Are you on birth control? No Yes Are you pregnant? No Yes 1 of 5

DOB: / / 1. PAST PSYCHIATRIC HISTORY Have Your Ever Been Admitted To A Psychiatric Hospital: No Yes Number of times: Date of Last hospitalization: Date of First Hospitalization: Have you seen a psychiatrist before: No Yes How about a therapist: No Yes Any history of: Suicidal thoughts Suicidal Gestures Suicide Attempts History of self-harm/self-mutilation Please Explain: Have you ever taken any psychiatric medications other than those listed as current? Please list: Medication Dates/Duration Dosage Response Reason Discontinued 2. SUBSTANCE ABUSE HISTORY please complete if applicable No Yes/Past or Yes/Now Route How Much How Often Date/Time of Last Use Quantity Last Used Alcohol Caffeine (pills or beverages) Cocaine Crystal Meth- Amphetamine Heroin Inhalants LSD or Hallucinogens Marijuana Methadone Pain Killers 2 of 5

No Yes/Past or Yes/Now Route How Much How Often Date/Time of Last Use Quantity Last Used PCP Stimulants (pills) Tranquilizers/ Sleeping Pills Ecstasy Other Have you ever been arrested or convicted? No Yes: When for (check below): DWI Drug Related Domestic Violence Other: Do you currently have scheduled court hearings, probation officer on parole, if yes, please explain: If yes, who is your P.O? Have you ever been in drug treatment in any of the following settings: Treatment Date(s) Provider s Name Place of Treatment Outpatient SA Counseling IOP Detox Program Residential Treatment Suboxone Medication Other: 3 of 5

DOB: / / 3. MEDICAL HISTORY Medication Allergies: None or List Are you diagnosed with: No current medical problems Asthma High blood pressure Diabetes Heart Disease Stroke Thyroid High cholesterol Cancer Other Medical Problems: please list Surgeries: No Yes Head Injury: No Yes Loss of consciousness: No Yes Seizures: No Maybe Yes 4. FAMILY PSYCHIATRIC HISTORY, Any one in your family suffers from: Depression Anxiety Disorder Bipolar disorder Alcoholism Drug Abuse Schizophrenia Suicide Homicide 5. SOCIAL HISTORY Birthplace # of siblings: Birth order: Occupation of Mother: Father: History of abuse: No Yes If yes, was it (circle all that applies) Verbal physical Sexual Who raised you? How was your childhood? How far did you go in school: GED: No Yes College: Post Grad: Have you ever skipped a grade: No Yes Were you in special Education: No Yes Problems in School: No Yes Explain: _ What do you do for a living? Current Employment: How long at current job: Marital Status Married In a relationship Single Divorced Separated Widowed # of children: Sexuality Heterosexual Homosexual Bisexual Military Experience No Yes Who do you live with: Current Social Support: Spirituality: Any problems with the law (current or past): No Yes Hobbies / Interests: 4 of 5

DOB: / / / 6. CURRENT HEALTH CARE PROVIDORS: For Permission to Contact any of them, Please check the appropriate box: PREVIOUS PSYCHIATRIST: Phone ( ) - Address: Contact: No Yes CURRENT PSYCHOTHERAPIST/COUNSELOR: Phone ( ) - Contact: No Yes CURRENT PRIMARY CARE PHYSICIAN: Phone ( ) - Address: Contact: No Yes SPECIALIST: Address: Phone ( ) - Do we have your permission to contact the above clinicians? No Yes If no, please explain: 7. Treatment Goals: (What would you like to achieve from visiting the clinic, please list according to their importance) (1) (2) (3) Is there anything else you would like to tell us about yourself? Print Name: Signature: Date Patient, or parent of child under the age of 18, must sign above. Thank you. 5 of 5

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