Email Form

DBT Center of San Diego
Client Information Form

Your birthday, the last four digits of your Social Security Number, and date of your first DBTCSD therapy session are needed for us to identify your data while keeping it anonymous to others.

Birthday
Social Security Number	(last four digits only)
First Session was on
Therapist	(primary therapist)

How many other people do you live with?
List everyone living in your house.

Name	Age	Relationship to you

How many children do you have?
List below any children that are not listed above.

Name	Age	Where is child living?

Birth country

PHYSICAL HEALTH

Primary Physician Phone Last visit:

Your height (feet) (inches)
Current weight Lowest adult weight: Highest adult weight:

Has a medical doctor ever tested you to examine if your psychological problems could be due to an underlying medical condition?

The following medical conditions are associated with mood disorders. Please indicate if you have had any of the following conditions.

Degenerative neurological illnesses:
       Parkinson's disease
       Huntington's disease
       other neurological illnesses
Metabolic or endocrine conditions
       B-12 deficiency
       hypothyroidism
       hyperthyroidism
       other metabolic or endocrine disorder
Autoimmune conditions
       systemic lupus erythomatosis
       other autoimmune disorder
Other disorders
       cerebrovascular disease
       hepatitis
       mononucleosis
       HIV
       cancer

What other chronic medical conditions?

How many head injuries have you had?
            When was the most severe injury? (month) (year)
            For how many minutes did you lose consciousness? (minutes)

PSYCHIATRIC MEDICATIONS

Name of Psychiatrist: Phone Number:

Please enter your current prescriptions for psychiatric medications

Medication	Dose	Prescribed for	Last name of prescribing doctor	Supply
				days
				days
				days
				days
				days
				days
				days
				days
				days
				days
				days

MEDICATIONS FOR PHYSICAL CONDITIONS

Do you currently take medications for any physical condition?

Medication	Dose	To treat what?	Obtained from	Supply
				days
				days
				days
				days
				days
				days
				days
				days
				days
				days

TREATMENT HISTORY

Please list your six most recent outpatient psychotherapists or counselors.

Name	Phone Number or City	Start Date	End Date	# sessions

Any other outpatient counseling or psychotherapy not listed above?

How many times in your life have you gone to a hospital emergency room
              for suicidal behavior, suicide ideation, or intentional self-injury?
How many times in your life have you been admitted to a psychiatric hospital
              for suicidal behavior, suicide ideation, or intentional self-injury?

When was the most recent time you were an inpatient in a psychiatric hospital?
            Month: Year: Hospital Name: Length of Stay: days

When was the next most recent time you were an inpatient in a psychiatric hospital?
            Month: Year: Hospital Name: Length of Stay: days