Patient Psychiatric History

CONTROLLED SUBSTANCE POLICY

We are generally inclined to prescribe non-habit-forming medications. A habit-forming medication is often described as a “controlled substance”. Controlled substances are medications which include but are not limited to the following: Certain sleep medications (Ambien, Lunesta, Sonata, etc. and their generics); Benzodiazepines (Xanax, Ativan, Valium, Librium, Klonopin, etc and their generics) (Adderall, Vyvanse, Concerta, Ritalin, modafinil etc. and their generics); and Buprenorphine/Naloxone (Suboxone, Subutex).

Agreement and Informed Consent

I understand and agree to the following:

Medication(s) for the management of my medical condition will be provided as long as I follow the rules/terms/conditions of this agreement.
I will disclose to my provider every medication I am taking; this includes over the counter medications, vitamins, and supplements.
I always have the right to refuse or stop taking my medication(s), but that doing so may result in withdrawal symptoms with potentially severe medical consequences.
If a controlled substance is prescribed, it may be written for a limited quantity and/or a short duration.
I will take my medication(s) exactly as prescribed by my provider.
I am not allowed to change dosage amounts or alter the time schedule of taking the medication without first consulting my prescribing physician.
If I decide to stop a medication or decrease my dose without direct supervision from my provider, he/she is not responsible for any serious adverse reactions or consequences I may experience, including seizures or death.
Any medical treatment is a trial, and that continued prescription is contingent on evidence of benefit and improved functionality.
If a controlled substance is prescribed, a 90-day supply may not be provided.
Controlled substances can be habit forming and can put me at risk for developing physiological dependence, tolerance and withdrawal.
I agree to submit to urine or oral fluid drug screens to detect the use of illegal substances, non-prescribed, and prescribed medications at any time and without 24-hour notice as ordered by my provider.
Controlled substances may impair my alertness, cognitive ability, and reaction times.
I will exercise extreme caution when taking controlled substances and driving or operating heavy machinery.
I am aware that I could be charged with DUI or cause injury to myself or others if I choose to drive a vehicle while on controlled substances.
I will not combine controlled substances with the consumption of alcohol or other illegal drugs.
If there is concern for medication abuse, diversion (giving or selling the medication to others) or “doctor shopping” (obtaining similar medications from multiple prescribers), my care will be terminated at my provider’s discretion.
My provider has the right to contact proper authorities (such as the police, DEA etc.) if there is concern that this is occurring.
If responsible legal authorities have questions concerning my treatment, all confidentiality is waived, and these authorities may be given full access to my records for their investigation.
An appointment will be required for all refill requests I make.
Controlled substances will not be phoned in after business hours, on weekends or holidays.
At least 24 hours for prescription refills authorization is needed and that requests received after 3:00pm are handled the next business day.
I will keep my medication(s) locked in a safe place and will not share it with others.
Lost or stolen medications or prescriptions will only be replaced once, providing that I have a police report.
When refills are due, I will contact my provider at least one week prior to running out.
Any missed appointment may constitute treatment failure and discontinuation of my medication and/or discharge from Wilmington Mental Health.
My prescribing physician has permission to discuss medication details with my dispensing pharmacy and/or current and previous healthcare professionals at their discretion.
My prescribing physician will routinely access the Prescription Monitoring Program (PMP) to confirm controlled prescription medications I have purchased and which pharmacy they were purchased from.
If I am having withdrawal symptoms due to lost or stolen controlled prescriptions, I am responsible for going immediately to the ER or calling 911 to seek immediate medical attention.

General Guidelines

An initial face-to-face appointment and in-office visit every 90 days at a minimum may be required for all prescriptions of controlled medications. Wilmington Mental Health will not make exceptions to local or federal regulations. In addition, all patients participating in controlled substance psychiatry program must attend behavioral or psychological treatment at least once a month during or prior to scheduling an appointment with a psychiatrist.

We encourage you to call our office if you are experiencing adverse effects from a medication which does not constitute a medical or psychiatric emergency, but which you would like to discuss promptly. We do not prescribe benzodiazepines on a long-term basis. All benzodiazepines are classified by the FDA as controlled substances due to their potential for abuse and dependence. We do not prescribe benzodiazepines to patients who are taking daily opiate pain medication. We prescribe stimulant medications when appropriate diagnostic testing has previously been done and available for review, and the patient agrees that the potential benefits outweigh the potential risks. Stimulants are a class of medications which are commonly prescribed for ADHD (and occasionally for other disorders).

Female Patients

Patients who become pregnant are required to notify their provider immediately and understand this may result in tapering their controlled medications for the safety of the fetus. I understand that controlled substances can have adverse effects on a pregnancy and agree to inform my provider if I become pregnant, if I am planning to become pregnant, or believe I may be pregnant.

Termination

Failure to comply with this policy will result in the discontinuation of the medication(s) and/or termination from my provider’s care. I understand that I will be terminated from my treatment if I alter or forge a prescription, which is a felony and will be reported. I further understand that if I violate this contract, Wilmington Mental Health will contact me by phone and in writing that I will be discharged or have my care transferred.

I acknowledge the risks and potential benefits of treatment with controlled substances have been explained and I have had the opportunity to ask questions I may have. I also affirm I have the full right and power to sign and be bound by this agreement. I have read, understand, and accept all the terms in this agreement.

	Children	Brothers	Sisters	Father	Mother	Uncle/Aunt	Grandparents
Nervous Problem
Depression
Hyperactivity
Counseling
Psychiatric Medication
Psychiatric Hospitalization
Suicide Attempt
Death by Suicide
Drug or Alcohol Problem

	CHECK
1. Death of spouse
2. Divorce
3. Marital Separation from mate
4. Detention in jail or other institution
5. Death of a close family member
6. Major personal injury or illness
7. Marriage
8. Being fired at work
9. Marital reconciliation with mate
10. Retirement from work
11. Major change in the health or behavior of a family member
12. Pregnancy
13. Sexual Difficulties
14. Gaining a new family member (i.e., birth, adoption, older adult moving in, etc.)
15. Major business adjustment
16. Major change in financial state (i.e., a lot worse or better than usual)
17. Death of a close friend
18. Changing to a different line of work
19. Major change in number of arguments with spouse (i.e., a lot more or less)
20. Taking on a mortgage (for home, business, etc.)
21. Foreclosure on a mortgage or loan
22. Major change in responsibilities at work (i.e., promotion, demotion, etc.)
23. Son or daughter leaving home (marriage, college, military, etc.)
24. In-law troubles
25. Outstanding personal achievement
26. Spouse beginning or ceasing work outside the home
27. Beginning or ceasing formal schooling
28. Major change in living condition (i.e., new home, remodeling, deterioration, etc.)
29. Revision of personal habits (i.e., dress, associations, quit smoking, etc.)
30. Troubles with the boss
31. Major changes in working hours or conditions
32. Changes in residence
33. Changing to a new school
34. Major change in usual type and/or amount of recreation
35. Major change in church activity (i.e., a lot more or less)
36. Major change in social activities (i.e., clubs, movies, visiting, etc.)
37. Taking on a loan (i.e., car, tv, freezer, etc.)
38. Major change in sleeping habits (i.e., a lot more or less)
39. Major change in number of family get-togethers (i.e., a lot more or less)
40. Major change in eating habits (i.e., a lot more or less, eating hours, surroundings, etc.)
41. Vacation
42. Major holidays
43. Minor violations of the law (i.e., traffic tickets, jaywalking, etc.)

PATIENT PSYCHIATRIC HISTORY

PSYCHIATRIC HEALTH

PROVIDERS

PSYCHIATRIC QUESTIONNAIRE

FAMILY HISTORY