Beruflich Dokumente
Kultur Dokumente
A Celebration of Change
104 W Main St, Ste 203
Puyallup, WA 98371
(253) 770-2332
Date: ______________________
Address: ___________________________________________________________________________
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Have you received Mental Health Services before? Yes No Voluntary Involuntary
Do you have any current medical or health issues? Yes No If yes, please explain below
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Have you had any major medical problems in the past? Yes No If yes, please explain below
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Please list all medications you are taking; including over the counter drugs, vitamins, and herbs
Are you
Dosage/T Reason currently
Medication Name ime taking Prescribers name? taking?
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
Do you have allergies: Yes No If yes please list, include food, drugs, environmental and
3. ._____________________________________ 4. ______________________________________
Substance use:
____ Caffeine: Amount: __________ How often: ___________ How long have you been using: __________
____ Tobacco: Amount: __________ How often: ___________ How long have you been using: __________
____ Alcohol: Amount: __________ How often: ___________ How long have you been using: __________
____ Inhalants: Amount: __________ How often: ___________ How long have you been using: __________
____ Marijuana: Amount: __________ How often: ___________ How long have you been using: __________
____ Drugs: Type: __________ Amount: __________How often: _________How long have you been using:
__________
Type: __________ Amount: __________How often: _________How long have you been using:
__________
Please list who lives in your home and your relationship to them.
Are they living in
Name: age: relationship: your home?
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
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Education:
Are you experiencing financial problems? Yes No If yes, please circle which kind (Optional)
Additional Comments:
____________________________________________________________________________________
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Signature Date