Get A&M Christian Counseling Center Clinical Intake Form
_____________________________________ Have you ever been hospitalized for any mental health reasons? Yes____ No_____ When Where: Reason: Presenting problem / Diagnosis Psychotropic medications: Are you currently taking any psychotropic medications? Yes____ No____ (Specify current & past meds) Medication Condition Dosage Dates of usage Side effects Physician Alcohol/drug usage: Do you currently use alcohol or drugs? Yes____ No____ Describe the use of drugs and alcohol (type, amount, frequency.
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