Are you seeking a psychiatric/medication evaluation?
In the past 30 days, have you experienced any of the following? (Check all that apply)
Have you experienced trauma (e.g., abuse, violence, accidents, loss)?
Do you regularly use tobacco or nicotine products?
Have you or others been concerned about your use of the following?
Family history of addiction?
Personal, Family, and Social History
Would you describe your schooling experience as positive overall?
Are you currently enrolled in school or a training program?
How long do you typically stay in a job before changing roles?
Have you received mental health services in the past?
Have you ever received a mental health diagnosis?
Have you taken psychiatric medication in the past?
Have you ever been hospitalized for psychiatric reasons?
Have you participated in an Intensive Outpatient Program (IOP) or Partial Hospitalization Program (PHP)?
Have you attended any self-help or peer support groups?
