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Name
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First
Last
Primary reason for seeking treatment and/or previous diagnosis?
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When were you first diagnosed and by whom?
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Do you have a family history of mental illness? Please provide detail.
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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.
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Has there ever been a beneficial medication for this problem? If so, what was it?
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Are you over 21 and seeking treatment for an attention problem?
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Did you bring medical records from a previous psychiatric provider? If not, please arrange to have this done.
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Have you ever been on pain management? Are you currently being treated with Suboxone, Subutex or Methadone? If yes, please describe.
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Have you been or are you currently on probation, if so what was the charge?
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Are you under any court or legal pressure to be here for an evaluation today?
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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?
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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.
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Do you worry about your eating and weight? If yes, please provide details and any history of an eating disorder.
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Do you have trouble making or keeping friends? If yes, please explain more.
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Do you have trouble paying attention? If yes, please explain more.
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Do you often feel distrustful of others? If yes, please explain more.
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Do you often have strange thoughts? If yes, please describe the nature and details of those thoughts and when they started.
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Do you often hear voices? If yes, what exactly do you hear, how often and when did they start?
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Do you have to do things the same way or keep repeating them? If yes, please provide details.
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Do you exercise, meditate or engage in any other complimentary/alternative techniques to manage stress? If yes, please provide details.
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