Today's Date

What other programs have you/they attended?

Do you/they have a history of violence or aggression?

What is your/their mental health diagnosis?

Do you/they report to any outside agencies?

What medication are you/they currently on?

Do you have a current history of drug or alcohol?

What was your/their drug of choice?

Who referred you/them, how did you hear about our program?

Why are you/they seeking treatment now?

Do you/they have a history of suicidal thoughts or attempts?

Medicaid Number