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Please complete all information on this form It may seem long, but most of the questions require only a check, so it will go quickly. You may need to ask family members about the family history. Thank you!

Current Symptoms Checklist (Mark any symptoms that are present)
Have you ever had feelings or thoughts that you didn't want to live?*
If YES, Do you currently feel that you don't want to live? If NO, please select N/A*
Have you ever had an EKG?
What was the EKG results?
For Women Only - Are you currently pregnant or do you think you might be pregnant? *
Do you have any concerns about your physical health that you would like to discuss with us?
Have you or anyone in your family experience/ed the following?
When your mother was pregnant with you, were there any complications during the pregnancy or birth?
Have you had any past psychiatric history? *
Have anyone in your family been diagnosed with or treated for:
Has any family member been treated with a psychiatric medication ?*
Have you ever been treated for alcohol or drug use or abuse? *
Check if you have ever tried the following:
Were you adopted?
Do you have a history of being abused emotionally, sexually, physically or by neglect*
Educational Completion
Occupational History - Are You Currently?
Relationship History - Are you currently?
Sexual Orientation*
Legal History - Have you ever been arrested?
Spiritual History - Do you belong to a particular religion or spiritual group?
Do you find your involvement is helpful during this illness, or does the involvement make things more difficult or stressful to you?
Do you have secondary insurance?*
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