(Needs to be filled out prior to Appointment)


    ***Please bring all medications, supplements, herbs, regularly used over-the-counter medications to first appointment.***


    Current Medications (Including over the counter/supplements/herbs):
    Medical Conditions:

    Do you ever hear or see things that other people cannot ?
    Do you ever feel like other people are watching you ?
    Do you ever feel like other people are talking about you ?
    Do you ever feel like other people are laughing at you ?
    Do you have any special powers or gifts ?
    Do you know other people who have special powers or gifts ?
    Do you ever feel like other people can read your thoughts or control you ?
    Do you ever feel like someone else is putting thoughts inside your head ?
    Do you ever get messages from outside forces ?
    Do doctors have a hard time figuring out why you are sick ?



    Do you have any activity or chore that you must complete every day ?



    Please Circle the answer that best applies to you:
    Have you ever had a traumatic event that causes:


    Have you ever been diagnosed or thought you have: (Please check all that apply)

    Have you ever been to a Psychiatrist or Counselor :

    Year or Age Treatment Provider or Clinic How often seen
    Was this Psychiatrist/Counselor helpful:
    Diagnoses (if any) :



    Have you ever been prescribed psychiatric medicines?

    Year or Age Medication Name How often taken ?



    Year of Hospitalization Name of Hospital or Center Length of Stay Sobriety length after stay (if applicable)
    Where the hosplitalizations voluntary or involuntary :
    Was your stay helpful :
    Have you ever had ECT (electroconvulsive therapy) :



    Have you ever abused any of the following prescription drugs: (Please check all that apply)

    Are you now or have you ever used street drugs : (Please tik all that apply)

    Has anyone in your family ever attempted or committed suicide :



    Did you have any juvenile behavioral problem(s) : (Please tik all that apply)

    Have you ever had a head injury in which you were knocked unconscious? If so, please list your age at the time of the injury and how long you were unconscious.




    Please tik all that apply to you within the last month only:

    On your Body: