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