Mental Health Treatment History
Full Name:
Email:
Mental Health Treatment History
Are you currently seeing a prescribing provider for MH medications?
Yes
No
Name:
Are you currently seeing a MH therapist?
Yes
No
Name:
Current Mental Health Diagnosis:
Have you attended past treatment with a prescribing provider or MH therapist?
Yes
No
If yes, explain:
Past Mental Health Diagnosis:
Have you visited the emergency department for a psychiatric/mental health crisis?
Yes
No
If yes, explain:
Have you been psychiatrically hospitalized?
Yes
No
If yes, explain:
Have you attempted to harm yourself or attempted suicide?
Yes
No
If yes, explain:
Have you been diagnosed with a substance use disorder and undergone chemical dependency treatment?
Yes
No
If yes, explain:
Have you incurred or are currently involved in any legal charges?
Yes
No
If yes, explain:
Past Mental Health Medication Trials or Psychiatric Treatments
I have never taken medications for mental health
Medication/Treatment Name
Date(s) Taken
Response
Other Comments
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