BEHAVIORAL HEALTH INFORMATION
What services are you seeking? Therapy Med Management Skills Training
What is the main reason you’re seeking services at this time?
Please mark any concerns you or your child have in the following areas. (Select only those that apply to the client). sad, depressed cry easily mood swings can’t sleep sleeping too much tired often muscle tension can’t eat eating too much feel anxious, nervous panic/anxiety attacks often fearful, afraid easily startled feel overwhelmed worry often feel stressed feel worthless easily angered aggression irritability obsessive behaviors self harm behaviors thoughts of suicide nightmares flashbacks can’t remember things can’t concentrate hyperactivity problems learning hearing voices seeing things that are not there alcohol/drug use
The following symptoms affect or may be affected by your (or your child’s) behavioral health needs. Please check if any of the following are currently affecting your life. moving housing concerns homeless job loss death/grief concerns about children child with special needs abuse in family domestic violence alcohol/drugs in family concerns about a parent family conflicts divorce relationship concerns pregnancy physical health concerns legal issues/criminal record
Are you (or your child) currently taking any medications?
If yes, what? Other concerns or issues:
Client Name :
Relation to Client : SelfParent / GuardianLegal CustodianGuardianOther, as listed
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Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: BEHAVIORAL HEALTH INFORMATION
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