Initial Screening and History date



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Wyoming Behavioral Institute – Outpatient Clinic in Laramie
504 S 4th St.
Laramie, WY 82070
Phone: (307)742-9700 Fax: (307)742-9717

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Initial Screening and History
DATE: _____________

Chief Complaint
What brings you in today? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________

In your opinion how severe is the problem? (circle one) Mild / Moderate / Severe

How long have you had this problem? (circle one) Days / Weeks / Months / 1 year / years

Are you currently prescribed psychiatric medication YES NO

Are you currently in counseling / therapy YES NO

Therapist name: ______________________________________________________________________

Where they practice: __________________________________________________________________

How long have you been seeing them: ____________________________________________________
Psychiatric History

Prior diagnoses or treatment of any psychiatric / mental health problems NO YES

(if YES Provide diagnosis, date (s) of treatment & treatment - medication/therapy/inpatient treatment)

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________

Previous psychiatric hospitalization: NO YES (please provide details; where, date, reason)

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________

Previous suicidal ideation / attempts: NO YES (please provide details)

____________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________

CURRENT substance use:
Caffeine NO YES How daily / weekly _______________________________

Tobacco

Cigarettes NO YES How much daily__________________________________

Electronic cigarettes NO YES How much daily__________________________________

Chew NO YES How much daily__________________________________



Alcohol NO YES How often and much ______________________________

Illicit substances

Marijuana NO YES How often and much ______________________________

Cocaine NO YES How often and much ______________________________

Methamphetamines NO YES How often and much ______________________________

Opioids / narcotics NO YES How often and much ______________________________

Mushrooms NO YES How often and much ______________________________

Ecstasy NO YES How often and much ______________________________

LSD NO YES How often and much ______________________________

PCP NO YES How often and much ______________________________

Inhalants NO YES How often and much ______________________________

Prescription pills (not prescribed to you) NO YES What and how often __________________
PAST substance use:
Tobacco

Cigarettes NO YES Age started:______When quit:_______________________

Electronic cigarettes NO YES Age started:______When quit:_______________________

Chew NO YES Age started:______When quit:_______________________



Alcohol NO YES Age at first use:______

Illicit substances (If yes provide additional information about when started, frequency, when quit)

Marijuana NO YES _______________________________________________

Cocaine NO YES _______________________________________________

Methamphetamines NO YES _______________________________________________

Opioids / narcotics NO YES _______________________________________________

Mushrooms NO YES _______________________________________________

Ecstasy NO YES _______________________________________________

LSD NO YES _______________________________________________

PCP NO YES _______________________________________________

Inhalants NO YES _______________________________________________

Prescription pills (not prescribed to you) NO YES ___________________________________
Previous outpatient treatment for alcohol / substances NO YES (provide additional info)

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Previous inpatient treatment for substances NO YES (provide additional info)

__________________________________________________________________________________________

__________________________________________________________________________________________

Personal History
Current Grade:_____________________________________________________________________________

Current School: ____________________________________________________________________________

IEP / 504: YES NO For what: ______________

Graduated High School YES NO Year ______________

GED YES NO Year ______________

Attended college – didn’t graduate YES NO

Highest Level of education: _________________________________________________________________

Graduated college / trade school YES NO

Trade (college, major, year): ________________________________________________________________

Associates (college, major, year):_____________________________________________________________

Bachelors (college, major, year): _____________________________________________________________

Masters (college, major, year): ______________________________________________________________

PhD (college, major, year): _________________________________________________________________

Primary Language Spoken: English / Spanish / Other: _____________

Have you ever served in the military? YES NO

If yes, what branch and when? ________________________________________________________________


Currently married or significant other: YES NO Spouses/significant others name:__________________________

Spouse’s occupation __________________________________Spouse’s education level: __________________

Previous marriage(s) NO YES How many ______

Dates of marriage(s) __________________________________________________________________________

Children: NO YES (number of children) _______

Child Name & Ages (specify if biological, adopted, step, & previous or current relationship): __________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________


Previous legal problems? YES NO If yes, provide details

__________________________________________________________________________________________

__________________________________________________________________________________________
Current legal problems? YES NO If yes, provide details

__________________________________________________________________________________________

__________________________________________________________________________________________

Family History

Siblings and ages (please indicate full, half, step, adopted): __________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

BORN: _______________________________________________________________________________

Natural Father: Name: ________________________________________________________________________

Occupation: ____________________________Highest level of Education: _______________________

If living, age: _____ and health: _____________________________________

If deceased, age, __________ year: ______ and cause: _______________________________________

Natural Mother: Name: ______________________________________________________________________

Occupation: ____________________________Highest level of Education: _______________________

If living, age: _____ and health: _____________________________________

If deceased, age, __________ year: ______ and cause: _______________________________________

If applies

Step / Adoptive Father: Name:_________________________________________________________________

Occupation: ____________________________Highest level of Education: _______________________

If living, age: _____ and health: _____________________________________

If deceased, age, __________ year: ______ and cause: _______________________________________

Step / Adoptive Mother: Name:________________________________________________________________

Occupation: ____________________________Highest level of Education: _______________________

If living, age: _____ and health: _____________________________________

If deceased, age, __________ year: ______ and cause: _______________________________________


Developmental (child / adolescent only)

If unknown please explain: ___________________________________________________________________



Pregnancy: easy moderate hard

Was alcohol, tobacco or illicit substances use during pregnancy YES NO

Were prescription medications taken during pregnancy YES NO

Additional information: ______________________________________________________________________



Delivery: vaginal c-section induced long labor

Complications: ____________________________________________________________________________



Weeks at birth: 28 29 30 31 32 33 34 35 36 37 38 39 40 41

Birth Weight: _______________

Postpartum: required oxygen jaundice intubated

Complications: ____________________________________________________________________________



Motor Skills:

Age at crawling: ________________________Age at walking: ________________________

Age began babbling: _____________________Age began talking: ____________________
Medical History:

Primary Care Provider: __________________________________________Last seen:____________________

Current medical problems:____________________________________________________________________ __________________________________________________________________________________________

__________________________________________________________________________________________

Past medical history:_________________________________________________________________________ __________________________________________________________________________________________

__________________________________________________________________________________________

Surgical History with dates: ___________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

History of Seizures NO YES _______________________________________________

History of Head Injuries NO YES _______________________________________________
Medication:

Allergies to medications: NKDA YES (what & reaction)

____________________________________________________________________________________________________________________________________________________________________________________

Food Allergies: NKA YES (what & reaction)

___________________________________________________________________________________________________________________________________________________________________________________Current Medications: (psychiatric / medical / herbal supplements / over the counter)

Medication dose frequency Prescribing Provider Reason

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________PAST Psychiatric medications prescribed ~ NOT currently taking:

Medication Prescribing Provider Date stopped taking Reason for Stopping



__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


Time

Relationship if other than self

Date

Patient/Authorized Representative Signature











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