Historical Information Provided By Family Member Or Other Concerned Party - El Dorado County Page 3

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Name of Consumer/Client:
Please check symptoms or behaviors that consumer/client has had in past when decompensating (becoming
unstable) and indicate which ones you are observing now.
Symptom or Behavior
Past
Now
Symptom or Behavior
Past
Now
Homelessness or Running Away
Suicidal Gesture/Attempts
Avoiding Others or Isolating
Suicide Statements
Not Answering Phone/Turning Off
Thinking About Suicide
Voicemail
Giving Away Belongings
Afraid to Leave Home
Stopping Medication
Being Too Quiet
Substance Use/Abuse
Crying/Weepiness
Taking More Medication Than
Lack of Motivation
Prescribed
Irrational Thought Patterns
Expressing Feelings of Worthlessness
(Not Making Sense)
Anxious and Fearful
Hearing Voices
Talking Too Much, Too Fast, Too Loud
Poor Hygiene
Spending Too Much Money
Cutting Self
Impulsive Behavior
Harming Self
Laughing Inappropriately
Failing to go to Doctor’s Appointments
Argumentative
Sexual Harassing/Preoccupation
Sleeping Too Much
Fire Setting
Not Sleeping
Aggressive Behavior (Fighting)
Not Eating
Destruction of Property
Over Eating
Increased Irritability and/or Negativity
Repetitive Behaviors
Making Threats of Violence
Forgetfulness
Not Paying Bills
Please describe recent history and behaviors that indicate dangerousness to self, dangerousness to others
and/or make the consumer unable to care for him/her self:
Information Submitted By:
Name (print): ______________________________________________________ Phone:
Address:
City/State/Zip
Signature: ________________________________________________________ Date:
A person “shall be liable in a civil action for intentionally giving any statement that he or she knows to be false”
(Welfare & Institutions Code Section 515.05(d))
Page 3 of 4
Updated 6-2-2014

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