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

Other
Is there a Family History of mental health problems?
Are your parents still married?
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?
If so, when and where?
Have you ever been hospitalized for mental health?
If so, when and where?
Have you had suicidal thoughts?
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
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Behavioral Health Social History Form

Social History

Reason for visit:

Mental Health History: