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Patient Information Form (DBT San Diego)
Fill out this information for the primary client.
First Name of the Client
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Last Name
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Date of Birth
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Home Phone
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Mobile Phone
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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.
Your answer
Home Address - Street Name and Number
Primary home address
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Home Address - City (Local)
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Home Address - Zip Code
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Are you currently employed or attending school?
Work Phone
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Highest grade/degree completed
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Ethnic background
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Current religious/spiritual affiliation or identity
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Make, model, year, and color of your car
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License plate number of your car
Your answer
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?
Have you thought about or attempted to kill yourself in your lifetime?
When was the most recent time you attempted to kill yourself?
How many times in your life, because of suicidal behavior or ideation, or self-injury, have you gone to a hospital emergency room?
Your answer
How many times in your life, because of suicidal behavior or ideation, or self-injury, have you been admitted to a psychiatric hospital?
Your answer
When was the most recent time?
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What was the name of the psychiatric hospital the most recent time?
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When was the NEXT most recent time before that?
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What was the name of the psychiatric hospital that NEXT most recent time?
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Is a gun kept in your home?
How many psychiatric medications are you currently taking?
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Name of Current Psychiatrist
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Phone Number of Current Psychiatrist
Your answer
List current medications for psychological or behavioral problems
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Do you get any of these medications from someone other than the psychiatrist mentioned above?
Name of another mental health treatment provider who knows you very well.
This can be a former therapist, counselor, or psychiatrist
Your answer
Phone number of the other mental health treatment provider who knows you well.
Your answer
Have you ever been diagnosed with bipolar disorder?
List other psychiatric disorders that you have been diagnosed with:
Your answer
Do you have panic attacks?
Do you have a problem with severe shame or self-hatred?
Current height (feet)
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Current height (inches)
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Current weight
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Lowest weight
Report your lowest adult weight ever.
Your answer
Heaviest weight
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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?
Is the primary client an individual adult, a couple, or a minor?
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