NEW PATIENT DEMOGRAPHIC INFORMATION
Current Therapist/Counselor
Current psychiatrist
What are the problem(s) for which you are seeking help
1.
2.
3.
Past Outpatient treatment
Yes
No
Psychiatric Hospitalization
Yes
No
Describe for what reason, when and where.
Psychiatric Medications
If you ever been prescribed any psychiatric medication or are you currently taking any medication for mental health.
Current
Past
1
2
Past suicidal ideation/ attempt / plan
Done
