Index

History(please explain in detail)

DOB:

Date of Referral:

Patient Name:

OMHC Psychiatry | Therapy

Reffering Department

Primary Substance

How often are you using?

How much are you using?

Longest Period of Abstinece?

Last Use: MM/DD/YYY

Any withdrawl symptoms?

Any legal concerns related to use?

Secondary Substance:

How often are you using?

How much are you using?

Longest Period of Abstinece?

Last Use: MM/DD/YYYY

Any withdrawl symptoms?

Any legal concerns related to use?

Tertiary Substance

How often are you using?

How much are you using?

Longest Period of Abstinece?

Last Use: MM/DD/YYYY

Any withdrawl symptoms?

Any legal concerns related to use?

Physical Disabilities?

Pregnancy Status(Females Only)

Psychiatric Condition?

Medical Condition?

Additional Information

Military Experience? Yes/No and if Yes -(which branch)

Still Active?

Screening Tool Completed (DAST,SBIRT,NM-ASSIST,AUDIT-C, etc. (yes or no)

Referring Provider

Date: MM/DD/YYYY

Reviewer

Date MM/DD/YYYY

Appt. Scheduled(yes/no)