La Fe Clinic
I have read and agree with what is stated in all TERMS AND CONDITIONS Check
I have read and agree with what is stated in CONSENT FOR INTEGRATED BEHAVIORAL HEALTH Check
I have read and agree with what is stated in CONSENT FORM FOR PSYCHOTROPIC MEDICATION Check
I have read and agree with what is stated in TELEHEALTH CONSENT FORM Check
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Primary Care Provider:
Emergency Contact Name & Phone:
REFERRED BY SelfPrimary Care ProviderFamily/FriendInsuranceTherapistOther
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REASON FOR TODAY’S VISIT Please briefly describe the main reason for your visit:
Current Symptoms
Depression or sadnessAnxiety or excessive worryPanic attacksMood swingsIrritability or angerDifficulty sleepingSleeping too muchLow motivationLow energy or fatigueDifficulty concentratingRacing thoughtsTrauma or PTSD symptomsObsessive thoughtsCompulsive behaviorsHearing voices or seeing thingsMemory problemsHyperactivity or impulsivityChanges in appetite or weightAlcohol or substance useSuicidal thoughtsSelf-harm behaviors
Other Symptoms
How long have these symptoms been present?
Less than 1 month1–6 months6–12 monthsMore than 1 year
How severe are your symptoms today? (1 = Mild, 10 = Severe)
Have you previously seen a psychiatrist, therapist, or counselor?
YesNo
Previous psychiatric diagnoses
Previous psychiatric medications
Have you ever been hospitalized for mental health reasons?
If yes, when and why?
Alcohol NoYes
Marijuana NoYes
Nicotine/Vaping NoYes
Other substances NoYes
If yes, please describe frequency
High blood pressureDiabetesThyroid disorderHeart diseaseSeizuresSleep apneaChronic painNeurological condition
Other medical conditions
Current medications
Allergies
Relationship status
SingleMarriedDivorcedWidowedPartnered
Employment status
EmployedSelf-employedStudentRetiredUnemployed
Who do you currently live with?
What are you hoping to improve with treatment?
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