Behavioral Health Social History Form WellAdvantage

Behavioral Health Social History Form

Tell us a little about yourself to help us get to you know better
Patient Gender*
Patient Name*

First NameLast Name
Patient Birth Date*

MonthDayYear
Patient E-Mail*
example@example.com
Social History
Are you married or in a committed relationship?*

YesNo
If so, how long?
Do you have any children?*

YesNo
If so, how many?
List all the members presently living in your household with their relationship and ages:*
i.e. spouse, age 45; child age 19, etc
Are you employed?*

YesNo
If so, what do you do?
Who do you consider your support system? *
Tell us about your favorite hobby?*
What do you do to unwind after a stressful day?*
Has anyone ever expressed concern about your alcohol consumption?*

YesNoOther
Is there a Family History of mental health problems?*

YesNo
Are your parents still married?

YesNo
Reason for visit:
Please describe the present problem for which you are seeking treatment (please provide as many details as possible): *
When did the problem start/did you first notice it? *
What have you done to resolve the problem? *
What do you believe is the main cause of the problem? *
i.e. job, family, health, etc.
Mental Health History:
Have you been treated previously for mental health or substance use?*

YesNo
If so, when and where?
Have you ever been hospitalized for mental health?*

YesNo
If so, when and where?
Have you had suicidal thoughts?*

YesNo
If so, when?
Have you or a family member had past suicidal attempts? If so, how? *
How will you know when you are feeling better? *
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Behavioral Health Social History Form

Social History

Reason for visit:

Mental Health History: