Adult Clinical Information and History

Is it OK to leave message at: (Please Check all that apply)
Is it okay to send a consultation note to your PCP or other providers of care after your visit? Indicate "Yes" unless you would prefer privacy. *

Brief description of the current situation and why you are seeking help at this time

Current Symptoms

Current Symptoms: *

Past Medical History

Please indicate if you have had any of the following tests completed in the past:

Current Medications

Previous Psychiatric Medications

Previous Psychiatric Medications

Substance Use

Substance Use Treatment History

Review of Systems

Please indicate if you have any problems/issues with the following

Family Psychiatric/Medical History

Social History

Do you: *