PATIENT AND CLINIC INFORMATION

Patient Name:

Date of Birth:

Age:

Phone Number:

Patient Email:

Allergies:

Select the one that applies to you

Primary Care Provider

Mental Health Provider

Primary Care/ Mental Health Provider Address:

Provider Email:

Phone Number:

Fax Number:

Mental Health Provider's Clinical Email Address:

THERAPY OPTIONS

Check all that apply

PATIENT DEPRESSION HISTORY

Duration of Current Symptoms:

Suicidal Ideations Present?

Yes

No

Has the patient attempted suicide in the past?

Yes

No

Is the patient currently taking anti-depressants?

Yes

No

Have the medications been effective in reducing depression symptoms?

Yes

No

Current antidepressant medications, dosages, and start date of therapy:

If the patient is not currently taking any anti-depressants, have they taken them before?

Yes

No

Please list previous medications, dates of usage, start/stop dates which were ineffective for treatment of depression:

Other notes about the patient's history of depression:

Referring Provider Name and Title:

Signature:

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Date: