Wyoming Behavioral Institute – Outpatient Clinic in Laramie
504 S 4th St.
Laramie, WY 82070
Phone: (307)742-9700 Fax: (307)742-9717
Initial Screening and History
DATE: _____________
Chief Complaint
What brings you in today?
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In your opinion how severe is the problem? (circle one) Mild / Moderate / Severe
How long have you had this problem? (circle one) Days / Weeks / Months / 1 year / years
Are you currently prescribed psychiatric medication
YES
NO
Are you currently in counseling / therapy
YES
NO
Therapist name: ______________________________________________________________________
Where they practice: __________________________________________________________________
How long have you been seeing them: ____________________________________________________
Psychiatric History
Prior diagnoses or treatment of any psychiatric / mental health problems NO
YES
(if YES Provide diagnosis, date (s) of treatment & treatment - medication/therapy/inpatient treatment)
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Previous psychiatric hospitalization: NO
YES (please provide details; where, date, reason)
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Previous suicidal ideation / attempts: NO
YES (please provide details)
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1
Wyoming Behavioral Institute – Outpatient Clinic in Laramie
504 S 4th St.
Laramie, WY 82070
Phone: (307)742-9700 Fax: (307)742-9717
CURRENT substance use:
Caffeine
NO
Tobacco
Cigarettes
NO
Electronic cigarettes
NO
Chew
NO
Alcohol
NO
Illicit substances
Marijuana
NO
Cocaine
NO
Methamphetamines
NO
Opioids / narcotics
NO
Mushrooms
NO
Ecstasy
NO
LSD
NO
PCP
NO
Inhalants
NO
Prescription pills (not prescribed to you)
YES
How daily / weekly _______________________________
YES
YES
YES
YES
How much daily__________________________________
How much daily__________________________________
How much daily__________________________________
How often and much ______________________________
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
How often and much ______________________________
How often and much ______________________________
How often and much ______________________________
How often and much ______________________________
How often and much ______________________________
How often and much ______________________________
How often and much ______________________________
How often and much ______________________________
How often and much ______________________________
YES What and how often __________________
PAST substance use:
Tobacco
Cigarettes
NO
YES Age started:______When quit:_______________________
Electronic cigarettes
NO
YES Age started:______When quit:_______________________
Chew
NO
YES Age started:______When quit:_______________________
Alcohol
NO
YES Age at first use:______
Illicit substances (If yes provide additional information about when started, frequency, when quit)
Marijuana
NO
YES _______________________________________________
Cocaine
NO
YES _______________________________________________
Methamphetamines
NO
YES _______________________________________________
Opioids / narcotics
NO
YES _______________________________________________
Mushrooms
NO
YES _______________________________________________
Ecstasy
NO
YES _______________________________________________
LSD
NO
YES _______________________________________________
PCP
NO
YES _______________________________________________
Inhalants
NO
YES _______________________________________________
Prescription pills (not prescribed to you) NO
YES ___________________________________
Previous outpatient treatment for alcohol / substances
NO
YES (provide additional info)
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Previous inpatient treatment for substances
NO
YES (provide additional info)
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Wyoming Behavioral Institute – Outpatient Clinic in Laramie
504 S 4th St.
Laramie, WY 82070
Phone: (307)742-9700 Fax: (307)742-9717
Personal History
Current Grade:_____________________________________________________________________________
Current School: ____________________________________________________________________________
IEP / 504:
YES NO
For what: ______________
Graduated High School
YES NO
Year ______________
GED
YES NO
Year ______________
Attended college – didn’t graduate YES NO
Highest Level of education: _________________________________________________________________
Graduated college / trade school
YES NO
Trade (college, major, year): ________________________________________________________________
Associates (college, major, year):_____________________________________________________________
Bachelors (college, major, year): _____________________________________________________________
Masters (college, major, year): ______________________________________________________________
PhD (college, major, year): _________________________________________________________________
Primary Language Spoken: English / Spanish / Other: _____________
Have you ever served in the military? YES NO
If yes, what branch and when? ________________________________________________________________
Currently married or significant other:
YES
NO
Spouses/significant others name:__________________________
Spouse’s occupation __________________________________Spouse’s education level: __________________
Previous marriage(s) NO
YES How many ______
Dates of marriage(s) __________________________________________________________________________
Children:
NO
YES (number of children) _______
Child Name & Ages (specify if biological, adopted, step, & previous or current relationship):
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Previous legal problems? YES
NO
If yes, provide details
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Current legal problems? YES
NO
If yes, provide details
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Wyoming Behavioral Institute – Outpatient Clinic in Laramie
504 S 4th St.
Laramie, WY 82070
Phone: (307)742-9700 Fax: (307)742-9717
Family History
Siblings and ages (please indicate full, half, step, adopted):
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BORN: _______________________________________________________________________________
Natural Father: Name:________________________________________________________________________
Occupation: ____________________________Highest level of Education: _______________________
If living, age: _____ and health: _____________________________________
If deceased, age, __________ year: ______ and cause: _______________________________________
Natural Mother: Name: ______________________________________________________________________
Occupation: ____________________________Highest level of Education: _______________________
If living, age: _____ and health: _____________________________________
If deceased, age, __________ year: ______ and cause: _______________________________________
If applies
Step / Adoptive Father: Name:_________________________________________________________________
Occupation: ____________________________Highest level of Education: _______________________
If living, age: _____ and health: _____________________________________
If deceased, age, __________ year: ______ and cause: _______________________________________
Step / Adoptive Mother: Name:________________________________________________________________
Occupation: ____________________________Highest level of Education: _______________________
If living, age: _____ and health: _____________________________________
If deceased, age, __________ year: ______ and cause: _______________________________________
Developmental (child / adolescent only)
If unknown please explain: ___________________________________________________________________
Pregnancy: easy moderate
hard
Was alcohol, tobacco or illicit substances use during pregnancy YES
NO
Were prescription medications taken during pregnancy
YES
NO
Additional information: ______________________________________________________________________
Delivery: vaginal
c-section
induced
long labor
Complications: ____________________________________________________________________________
Weeks at birth: 28 29 30 31 32 33 34 35 36 37 38 39 40 41
Birth Weight: _______________
Postpartum: required oxygen
jaundice intubated
Complications: ____________________________________________________________________________
Motor Skills:
Age at crawling: ________________________Age at walking: ________________________
Age began babbling: _____________________Age began talking: ____________________
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Wyoming Behavioral Institute – Outpatient Clinic in Laramie
504 S 4th St.
Laramie, WY 82070
Phone: (307)742-9700 Fax: (307)742-9717
Medical History:
Primary Care Provider: __________________________________________Last seen:____________________
Current medical problems:____________________________________________________________________
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Past medical history:_________________________________________________________________________
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Surgical History with dates: ___________________________________________________________________
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History of Seizures
NO
YES _______________________________________________
History of Head Injuries
NO
YES _______________________________________________
Medication:
Allergies to medications: NKDA
YES (what & reaction)
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Food Allergies: NKA
YES (what & reaction)
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Current Medications: (psychiatric / medical / herbal supplements / over the counter)
Medication
dose frequency
Prescribing Provider
Reason
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PAST Psychiatric medications prescribed ~ NOT currently taking:
Medication Prescribing Provider
Date stopped taking
Reason for Stopping
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Patient/Authorized Representative Signature
Relationship if other than self
Date
Time
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