DP Behavioral Health Survey

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Behavioral Health Survey

Use this form to request behavioral health treatment or information and referral services.

* Indicates required field

Name *

First

Last

Date of Birth *

Age *

Primary Language *

Marital Status *

Gender *

Male Female Transgender

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Emergency Contact *

First

Last

Emergency Contact Phone *

How Did You Hear About Dream Pathways *

I. Presenting Problem (Describe presenting problem) *

II. Family Background (Tell us about your family) *

III. Childhood (How was your upbringing) *

IV. Education (Last grade completed) *

V. Work History (List your 3 most recent jobs) *

VI. Legal History (List all arrests) *

VII. Medical History (List all medical conditions and hospitalizations) *

VIII. Psychiatric History (List all medications, diagnoses, and past psychiatric treatment, including inpatient and outpatient) *

IX. Substance Abuse History (What substances are you taking now? What substances have you taken in the past? Include frequency and dosage) *

X. Life Goals (Where do you see yourself in the next 5 years) *

XI. Coping Skills (How do you cope with stress?) *

XII. Services Needed (Check all that apply) *

Food Shelter Clothing Employment/Job Placement Trade/School Placement Relationship Counseling Individual Counseling Group Counseling

XIII. Group Counseling Interest Areas *

Anger Management Domestic Violence Substance Abuse Financial Counseling Assertiveness Training Esteem Building Trauma Counseling Parent Other

Submit

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