Please provide the name, location and phone number of your phrmacy.
Please provide the name and location of your primary care provider or type in N/A if you do not have one.
Why are you seeking consultation?
Please describe your mental health symptoms or concerns from the time of your first symptom to the present. When did they start? What have you experienced? How has it affected your functioning?
What mental health providers and treatment modalities have your worked with before?
What psychiatric medications and doses have you taken/been prescribed in the past and how did you respond to each them?
If “yes,” when was the last time?
If you checked any of the boxes above other than "I never have thought about suicide", please type when was the last time and how?
(Please type your answers in the space provided below)
If “yes,” to the above question, under what circumstances? Has alcohol use ever negatively impacted your education, work, relationships or mental health?
If you checked one or more of the drugs, under what circumstances did you take it (them)?
Has drug use ever negatively impacted your education, work, relationships or mental health? What is the most frequently you have ever used drugs?
When was the last time you took such drugs?
Please type in below-
Mothers Age (Or if deceased, age at death)
Mothers Occupation (Or if deceased, cause of death)
Major Illnesses Mother had
(List all major illnesses, including psychiatric, neurologic, alcoholism, drug abuse, suicide, and
suicide attempts)
Type in N/A if not applicable
Please type in below-
Fathers Age (Or if deceased, age at death)
Fathers Occupation (Or if deceased, cause of death)
Major Illnesses Father had
(List all major illnesses, including psychiatric, neurologic, alcoholism, drug abuse, suicide, and
suicide attempts)
Type in N/A if not applicable
Please type in below-
Brothers Age (Or if deceased, age at death)
Brothers Occupation (Or if deceased, cause of death)
Major Illnesses Brother had
(List all major illnesses, including psychiatric, neurologic, alcoholism, drug abuse, suicide, and
suicide attempts)
Type in N/A if not applicable
Please type in below-
Sisters Age (Or if deceased, age at death)
Sisters Occupation (Or if deceased, cause of death)
Major Illnesses Sister had
(List all major illnesses, including psychiatric, neurologic, alcoholism, drug abuse, suicide, and
suicide attempts)
Type in N/A if not applicable
Please type in below-
Grandparents, uncles, and aunts Age (Or if deceased, age at death)
Grandparents, uncles, and aunts Occupation (Or if deceased, cause of death)
Major Illnesses Grandparents, uncles, and aunts had (List all major illnesses, including psychiatric, neurologic, alcoholism, drug abuse, suicide, and
suicide attempts)
Type in N/A if not applicable
If checked above, explain circumstances.
How much and for how long?
If you indicated that you use caffeine above, how frequently and how much?
Please list all prescription and over the counter medications and supplements you are currently taking. Please also list any medication allergies. If you are not taking anything, please write N/A in the box below.
List all past and present medical problems as well as any surgery or accidents and the age when it first occurred.
Please describe the symptoms above
If you checked the box above, please explain which one, for how long, and if you have noticed any potential impact on your thoughts, feelings or behavior you have noticed.