ADULT CLINICAL QUESTIONNAIRE

Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Age
Marital Status
Children and Ages
Are You Working?
- Yes
- No
- Retired
Occupation
Are you receiving SSD Disability or have you applied for SSD?
- Yes
- No
Who do you live with?
Reason for coming to this clinic?
Name of current therapist
Current Therapist Phone
Current Psychiatric Medications
Name of Medication #1
Dose and Times
When Started
Concerns
Name of Medication #2
Dose and Times
When Started
Concerns
Name of Medication #3
Dose and Times
When Started
Concerns
Name of Medication #4
Dose and Times
When Started
Concerns
Past Psychiatric Medications
Name of Medication #1
Dose and Times
When Started
Concerns
Name of Medication #2
Dose and Times
When Started
Concerns
Name of Medication #3
Dose and Times
When Started
Concerns
Name of Medication #4
Dose and Times
When Started
Concerns
Have you had any allergic reactions to medications?*
- Yes
- No
If Yes, Please Explain
At what age did you first seek treatment for your mental health issues?
Hame you ever been hospitalized for mental health issues?*
- Yes
- No
If Yes, When and Which Hospital?
Are you currently in counseling or have you had counseling in the past?*
- Yes
- No
Family Mental Health History
Has anyone in your family been treated for mental health problems?
- Yes
- No
If yes, please explain

Current Psychiatric Medications