LOCAL INTAKE ASSESSMENT - Section 7 - Psychiatric

Local Full Name

First Name

Last Name

How would you rate your mental health?

Does local appear to be alert and fully oriented?

Date of most recent psychological evaluation

leave blank if local has never had one

MM

DD

YYYY

If Local has completed a psych eval, has it been received by Southwind Fields?

Yes

No

Name of Psychiatrist

First Name

Last Name

Psychiatrist Phone Number

(###)

###

####

Date of Last Visit

MM

DD

YYYY

Reason for last visit

Has local ever been hospitalized for psychiatric care? If so, when and for what reason?

Does local have a history of abuse or trauma that may impact their mental health or that SWF should know about?

Does the local have an eating disorder?

Has the local ever attempted to commit suicide or had suicidal or self-harming ideation? If so, when and how was it handled?

Does the local receive counseling? Or want to receive counseling?

Name of counselor

First Name

Last Name

Phone number of counselor

(###)

###

####

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