Behavioral Health Questionnaire - Bancroft Behavioral Health Inc

Name*

First Last

Primary reason for seeking treatment and/or previous diagnosis?*

When were you first diagnosed and by whom?*

Do you have a family history of mental illness? Please provide detail.*

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.*

Has there ever been a beneficial medication for this problem? If so, what was it?*

Are you over 21 and seeking treatment for an attention problem?*

Did you bring medical records from a previous psychiatric provider? If not, please arrange to have this done.*

Have you ever been on pain management? Are you currently being treated with Suboxone, Subutex or Methadone? If yes, please describe.*

Have you been or are you currently on probation, if so what was the charge?*

Are you under any court or legal pressure to be here for an evaluation today?*

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?*

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.*

Do you worry about your eating and weight? If yes, please provide details and any history of an eating disorder.*

Do you have trouble making or keeping friends? If yes, please explain more.*

Do you have trouble paying attention? If yes, please explain more.*

Do you often feel distrustful of others? If yes, please explain more.*

Do you often have strange thoughts? If yes, please describe the nature and details of those thoughts and when they started.*

Do you often hear voices? If yes, what exactly do you hear, how often and when did they start?*

Do you have to do things the same way or keep repeating them? If yes, please provide details.*

Do you exercise, meditate or engage in any other complimentary/alternative techniques to manage stress? If yes, please provide details.*