Treatment | Medication History
DEMOGRAPHICS
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OCCUPATION  / INSURANCE
Occupation *
Employer *
Insurer / Member Id# *
Group Number
Effective Date *
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Policy Holder Relationship *
TREATMENT HISTORY
Have you ever been in treatment with a psychiatric provider in the past (Psychiatrist orPsychiatric NP)? If so, when was the last time? Why did you leave your previous provider? Have you ever been discharged from treatment for missing appointments? For not following treatment recommendations? Or for threatening or aggressive behavior? *
If you have had a previous provider, are you willing to sign a ROI (Release of Information) for that provider so that we might obtain records? *
Have you ever been hospitalized for psychiatric reasons in the past? If so, how many times in the past year? And when was the most recent admission? *
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If yes when was the most recent admission?
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Have you ever been to the ER or Crisis Center for psychiatric reasons? If so, how many times in the last year? *
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If yes when was the most recent?
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Have you ever attempted suicide? If so, how many times? How many in the last year? *
Required
If Yes, when was the most recent?
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