New Patient History -

Name*

First Last

Referral Source

Date of Birth*

Social Security Number*

Employer*

Primary Care Physician*

Phone

Therapist/Psychologist*

Phone*

Pharmacy

Phone

Current medications:*

Please list drug, dose and prescriber

Allergies

Past psychiatric medications

Current medical issues you are being treated for:

Psychiatric history

(Please provide all past mental health and/or substance abuse treatment, including inpatient and outpatient)

Family history of mental illness/substance abuse issues:

Please list relationship to you and diagnosis.

Describe your current alcohol/tobacco/drug use habits: