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Screening Form

General Information
Client Name:
Phone#:
D.O.B:
Address:
Insurance Provider:
*Policy Holders Name:
*Policy Holders DOB:
Insurance Member ID:
Insurance Provider's Phone #:

Questions
How may we help you today:
Are you in Crisis (Refer to ER if Yes, no appointment):
Are you currently on psychiatric medications? If so, What are they?
Are you stable on your medications?
Are you currently seeing a psychiatrist? If yes, with whom and when last seen:
Are you currently seeing a therapist? If yes, with whom and when last seen:
Any Inpatient/Outpatient Treatment for Mental Health or Substance Abuse? If yes when and where:
Any History of Suicide attempt? If yes Please describe:
Do you feel you are a harm to yourself or others? If yes, any intent or plan?
Do you experience any symptoms of Depression, Anxiety, or Panic Attacks? If yes, how often?