• Clinical History Form

  • Please complete this form to the best of your ability, it will help your clinician to provide you with well informed care. However, if you're uncomfortable filling out any fields included you may leave them blank and they can be discussed at your intake.

  • Section 1: Overall Quality of Life

    Please select the answer that best applies to you for each statement on the scales below.

  • Section 2: Living Situation and Relationships

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  • Section 3: Family of Origin (Childhood Family)

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  • Section 4: Demographics

  • Section 5: Childhood Developmental History

  • Section 6A: Mental Health History

  • Section 6B: Treatment History

  • Section 7: Substance Use

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  • Section 8: Physical Health  (Almost done...)

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  • Section 9: Social and Spiritual Assets (Last section, you made it!)

     

  • Clear
  • Should be Empty: