Behavioral Health Questionnaire

Full Name(Required)

Primary reason for seeking treatment and/or previous diagnosis?(Required)

When were you first diagnosed and by whom?(Required)

Do you have a family history of mental illness? Please provide details.(Required)

Are you taking any medication at this time? Please list doses, times and when last take. Please include any supplements or alternative medication you are taking.(Required)

Has there ever been a beneficial medication for this problem? If so, what was it?(Required)

Are you over 21 and seeking treatment for an attention problem?(Required)

Did you bring medical records from a previous psychiatric provider? If not, please arrange to have this done.(Required)

Have you ever been on pain management? Are you currently being treated with Suboxone, Subutex or Methadone? If yes, please describe.(Required)

Have you been or are you currently on probation, if so what was the charge?(Required)

Are you under any court or legal pressure to be here for an evaluation today?(Required)

Are you here for reasons related to FMLA, Disability from work or problems at work of any kind that you need this evaluation for support of that problem?(Required)

Are you here for reasons related to school? Do you have problems at school with behavior, grades or skipping class? If yes, please provide details.(Required)

Do you worry about your eating and weight? If yes, please provide details and any history of an eating disorder.(Required)

Do you have trouble making or keeping friends? If yes, please explain more.(Required)

Do you have trouble paying attention? If yes, please explain more.(Required)

Do you often feel distrustful of others? If yes, please explain more.(Required)

Do you often have strange thoughts? If yes, please describe the nature and details of those thoughts and when they started.(Required)

Do you often hear voices? If yes, what exactly do you hear, how often and when did they start?(Required)

Do you have to do things the same way or keep repeating them? If yes, please provide details.(Required)

Do you exercise, meditate or engage in any other complimentary/alternative techniques to manage stress? If yes, please provide details.(Required)