Healthcare Psychiatric Questionnaire

Healthcare Psychiatric Questionnaire

Patient Information

Date of Birth:    Gender: Male Female Non-binary Other

Insurance Information

Presenting Problem

Primary reason for this evaluation:

Approximate onset date:    Duration:

Psychiatric History

Prior psychiatric hospitalizations: Yes No

History of suicide attempts or self-harm: Yes No

Medical History & Current Medications

Substance Use

Alcohol use:    Last use:

Tobacco/nicotine:    Last use:

Risk Assessment (Safety)

Current suicidal ideation: Yes No

Homicidal ideation or intent: Yes No

Functional & Social History

Mental Status Examination (brief)

Authorization, Confidentiality & Acknowledgment

By completing and signing below, I certify that the information provided in this questionnaire is accurate to the best of my knowledge. I understand that the clinician will use this information to evaluate and plan treatment and that false or omitted information may affect care.

I acknowledge that mental health records are confidential but may be disclosed without my consent where required or permitted by law, including but not limited to: reporting of child or elder abuse, imminent risk of serious harm to self or others, or court order. I authorize exchange of relevant information with my listed insurance carrier for purposes of treatment and payment as necessary.

Authorization expiration date (if not specified, authorization expires 1 year from date of signature):

I acknowledge receipt of the privacy practices and understand my rights regarding my health information. I understand that I may withdraw this authorization in writing at any time except to the extent that action has already been taken in reliance on it.

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