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Clients Legal Name*

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Age*

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Emergency Contact

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Do you give us permission to contact this person in an emergency?*

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Are you a danger to yourself or others?*

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Have you had any past suicide attempts?*

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In the last 12 months, have there been any thoughts of suicide, along with an intention and plan?*

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Currently, are there any thoughts of suicide along with an intention and plan?*

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Have you ever been hospitalized for a mental health condition?*

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Have you ever had a seizure?*

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Are you currently taking antipsychotic or other psychiatric medication?*

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Are you taking the medications as prescribed?*

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No medication prescribed

Do you have any diagnosed medical conditions?*

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Please list any immediate medical concerns*

Have you attended any drug and alcohol treatment centers in the past?*

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Do you drink alcohol?*

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Have you abused prescription medications or used street drugs in the past 6 months?*

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Date you last used drugs or drank alcohol?*

In the past 6 months, have you been arrested?*

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Briefly describe your relationship with your immediate family:*

In the past 6 months, have you held steady employment?*

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Please describe your willingness to be helped:*

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