Client/patient Questionnaire Form
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1M
H
S
U
--- C
/P
Q
ENTAL
EALTH AND
UBSTANCE
SE
LIENT
ATIENT
UESTIONNAIRE
This information may be shared with your family doctor and used within Island Health to provide you with the best possible care.
MRN
:
(office use only)
Please print clearly and fill out this form completely.
Name: ______________________________________________ Alias?________________
Today’s Date:___________________
dd-mmm-yyyy
M F Other
Gender:
Date of Birth_________________ PHN (care card) : 9____________________________________
dd-mmm-yyyy
Address: ________________________________________Postal Code____________
______________________
Family Physician
Yes No
Primary Phone #: ____________________ best time to call? _________________________ OK to leave message?
What would you like help with the most? ( e.g. mental health concerns, stressors, substance use)
Which type of service are you requesting? (please circle)
Detox
Substance use counselling (AOT)
Stabilization
Supportive Recovery
Mental health counselling
Not sure
Other:_________________________________________________________________________________________________
Aboriginal Identity Yes No Marital Status: _______________ Employment Status:____________ Source of Income_________________
Other services or support involved? __________________________ Education level? ______________ Legal involvement? ______________
Yes No How? ________________________________ Children in the home?
Yes No
Has violence been an issue in your life?
What are your goals regarding your substance use
Substance use (including tobacco)
and/or mental health?
Substance
Date last used
How much?
How often?
___________________________________________
___________________________________________
Do you have any medical concerns we should be
aware of? Yes No
If yes:
___________________________________________
Do you have problems with mobility (e.g. walking)?
Medications
Yes No
Name
Amount
Frequency
Are you at immediate risk of harming yourself or
others? Yes No
Are you able to remain safe? Yes No
Signature:___________________________________
(office use only):
CERNER
MH Intake Tracking System
PM Office
Systems Checked
Appointment date/time:____________________________________
MHDB
Powerchart reviewed by clinician
Message Log:
For Substance Use Intake Fax to (250) 213-4445 or (250) 519-3613
____________________________________________________
Phone (250) 213-4444
____________________________________________
____________________________________________
For Mental Health Intake Fax to (250) 381-3222 with Physician Referral
____________________________________________
Phone (250) 519-3485
____________________________________________
Rev. 08-May-2014
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Parent category: Life