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Patient Information Form
Fill out this information for the primary client.
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First Name of the Client *
Last Name *
Date of Birth *
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Home Phone
Mobile Phone *
Email Address
Only enter the email address of the primary client. If the primary client is an adolescent, do not enter the email address of a parent.
Home Address - Street Name and Number *
Primary home address
Home Address - City (Local) *
Home Address - Zip Code *
Are you currently employed or attending school?
Clear selection
Work Phone
Highest grade/degree completed
Ethnic background
Current religious/spiritual affiliation or identity
Make, model, year, and color of your car
License plate number of your car
Have you ever deliberately hurt yourself physically (e.g., cut or burned), but were not trying or expecting to die?
If so, when was the most recent time?
Clear selection
Have you thought about or attempted to kill yourself in your lifetime?
Clear selection
When was the most recent time you attempted to kill yourself?
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How many times in your life, because of suicidal behavior or ideation, or self-injury, have you gone to a hospital emergency room?
How many times in your life, because of suicidal behavior or ideation, or self-injury, have you been admitted to a psychiatric hospital?
When was the most recent time?
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What was the name of the psychiatric hospital the most recent time?
When was the NEXT most recent time before that?
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DD
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What was the name of the psychiatric hospital that NEXT most recent time?
Is a gun kept in your home? *
How many psychiatric medications are you currently taking? *
Name of Current Psychiatrist
Phone Number of Current Psychiatrist
List current medications for psychological or behavioral problems
Do you get any of these medications from someone other than the psychiatrist mentioned above?
Clear selection
Name of another mental health treatment provider who knows you very well.
This can be a former therapist, counselor, or psychiatrist
Phone number of the other mental health treatment provider who knows you well.
Have you ever been diagnosed with bipolar disorder?
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List other psychiatric disorders that you have been diagnosed with:
Do you have panic attacks?
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Do you have a problem with severe shame or self-hatred?
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Current height (feet)
Current height (inches)
Current weight
Lowest weight
Report your lowest adult weight ever.
Heaviest weight
Which of the following traumatic events have you experienced?
Have you experienced any of the following events?
Have you ever been charged with any of the following?
Substance Use
Have you ever driven while drunk or intoxicated on alcohol or drugs?
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Is the primary client an individual adult, a couple, or a minor? *
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