Date Format: MM slash DD slash YYYY
(please note whether living in or outside of the home)
Prior Mental Health Care
- First Mental Health Care
- Most Recent Care
FINANCIALLY RESPONSIBLE PARTY
An adult client or an adult guardian who has assumed the cost of treatment. Payment is expected at the time of service.
(# of siblings, marriages/significant relationships, children, impacting events, e.g. moves, developmental changes, sexual/physical/emotional abuse, trauma, divorce.)
(Current & past medications & dosages, illnesses, etc.)
(Client or Family)
(Arrests, violations, warnings, Conditional Discharge, DWIs, probation (past or present), guardianships, durable power of attorney, living wills, JSOs, DCYF involvement, etc.)
(i.e. Adhd, learning disabilities, depression alcoholism, anxiety) or neurological disorders (i.e. seizures, Tourettes, autism)
Prior Psychological Evaluations/Treatment
- Other care professionals you are currently undergoing treatment with (e.g. other medical professionals such as acupuncturist, chiropractor, medical specialists, etc.)
This field is for validation purposes and should be left unchanged.