Mental Health Form

Client's Name*

First Last

Date*

Treatment Coordinator / Therapist*

Phone*

Presenting Problems*

Diagnosis (DSM-V)

Diagnoses*

Relevant Psychosocial and/or Contextual Factors:*

History*

Current Medications (if none state "none")*

Drug	Dose	Route	Time	Purpose

Current Therapy (if none state "none")*

Where	When	Diagnosis

Outpatient Therapy (if none state "none")

Where	When	Diagnosis

Inpatient Therapy (if none state "none")

Where	When	Diagnosis