Your Age:

Appointment Date:

Primary Insurance?

Reason for consult?

Have you ever been admitted to psychiatry hospital?

Have you ever been diagnosed with Schizophrenia / Bipolar Disorder?

Do you have history of self- injurious behavior/ suicidal ideation / homicidal ideation?

Do you have history of auditory or visual hallucination / paranoia/substance use history?

Additional information/questions: