Psychiatric Intake Form Page 4
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11Past Psychiatric Treatment: (Include therapy, psychiatrists, hospitalizations, dates)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Substance Use and Addiction History:
Current Use (Please circle):
Methamphetamines Cocaine/crack Speed Heroin Ecstasy/MDMA Benzodiazepines Marijuana Behavioral
Addiction (gambling, compulsive behaviors, internet, sexual)
Past Use (Please circle):
Methamphetamines Cocaine/crack Speed Heroin Ecstasy/MDMA Benzodiazepines Marijuana Behavioral
Addiction (gambling, compulsive behaviors, internet, sexual)
Hallucinogens (mushrooms, LSD) Tobacco Alcohol
Caffeine
Hallucinogens (mushrooms, LSD) Tobacco Alcohol
Caffeine
Have you ever been treated for alcohol or drug use or abuse? Yes ( ) No ( )
If yes, for which substances?
_____________________________________________________________________________ If yes, where were you
treated and when? __________________________________________________________________
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