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Behavioral Health Intake Form

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What treatments have you had in the past?
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When did symptoms begin?
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How do you cope?
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Please mark which individual or group of symptoms you have had in the past or struggle with now:
A period over 4 or 7 days of:
A period over 2 weeks of:
What medications have you tried in the past? (Circle all that apply)
Serotonin Medication:
Mood Stabilizers:
Atypicals:
GABA Medications:
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Do you have any of the following medical conditions? (circle all that apply)
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Have you ever drank alcohol to excess?
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Do you use Cannabis products?
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Do you use Tobacco or Nicotine products?
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Any firearms in the home?
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Any history of legal convictions?
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