HEAL PSYCHIATRIC SERVICES
Name:*
D.O.B:*
Reason for consultation:
Past psychiatrist/Therapists (dates if possible):
Past psychiatric medications and response:
Current Psychiatric medications
Current Non-psychiatric Medications
Medical History (current and past)
Inpatient hospitalizations (which hospitals, when and for what reason)
Out-patient treatment programs IOP/PHP (which hospitals, when, for how long)
Substance Use History: (which drug, for how long have you used, treatment history including rehab, current use)
Suicidal Attempts (how many, how serious, did you get help?)
History of violence
Legal history (arrests, DUI’s, Jail etc, any current legal cases)