Intake Form - Counseling Life Wellness (Page 3 of 3) in pdf

Intake Form - Counseling Life Wellness Page 3

Medical History Questionnaire

NAME:

DOB:

BEHAVIORAL HEALTH HISTORY

13. Have you ever received out-patient (office-based) services, been hospitalized

No, go to question 14.

Yes, answer questions 13(a) – 13(c)

or received services in a residential facility for behavioral health concerns?

13(a) Describe below the type of treatment you received to address your behavioral health concerns and when you received treatment:

Type of Treatment

When and Where Received

13(b)

What current or prior treatment/services, including medications, do you think have been most helpful in addressing your

behavioral health symptoms? Explain:

13(c)

What current or prior treatment/services, including medications, do you think have been least helpful in addressing your

behavioral health symptoms? Explain:

14. Describe any current or past substance abuse in your family (For purposes of this question, “family” may include birth family,

foster family and/or family with whom person is or has lived.

Family Member

Current (Y/N)

Past (Y/N)

Description

Family history of mental health concerns (e.g. depression, anxiety, bipolar, schizophrenia, OCD, PTSD)

15.

Family Member

Current (Y/N)

Past (Y/N)

Description

Rev 2016 1127

Intake Form - Counseling Life Wellness Page 3