SELF INFORMATION FORM
SELKIRK MENTAL HEALTH CENTRE
You have been referred to the Dialectic Behaviour Therapy Program. We need some information from you to ensure our
program will meet your needs. If you are unable to complete this form by yourself, you can ask a friend or relative to help
you complete it or you may contact us toll free 1-800-881-3073 extension 618 (Dr. Holm) or extension 676 (Lynn Luining).
Please complete this form in black ink and return it to:
Young Building
Acute Program Manager
Selkirk Mental Health Centre
Box 9600
SELKIRK MB R1A 2B5
Fax: (204) 482-6390
CONTACT INFORMATION (please provide telephone number(s) where messages can be left)
Title:
Last Name:
Given Name:
Preferred Name:
Middle Name:
Maiden Name:
Gender:
Alias:
Address:
Transient
City:
Province:
Postal Code:
Phone:
Business Phone:
Ext.
E-mail:
Preferred Method of Contact:
Country:
Mobile Phone:
Date of Birth:
Phone
Health Card Number:
E-mail
Issuing Province:
Health Card Name (if different from above):
OR Reason for No Health Card #:
EMERGENCY CONTACT INFORMATION (please provide telephone number(s) where messages can be left)
Name:
Relationship to Patient:
Address (if different from above):
Province/State:
Phone:
City:
Postal/Zip Code:
Country:
Business/Alternate Phone:
Email:
SECOND EMERGENCY CONTACT INFORMATION (please provide telephone number(s) where messages can be left)
Name:
Relationship to Patient:
Address (if different from above):
Province/State:
Phone:
City:
Postal/Zip Code:
Business/Alternate Phone:
Country:
Email:
PHARMACY INFORMATION
Are you currently taking any prescription or over the counter medications?
Please list the medication and when you are taking it:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
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Pharmacy Name:
Address:
City:
Province:
Postal:
Phone:
DISCHARGE PLANNING
After discharge, would you have concerns about any of the following? (check all that apply)
Child care issues
Personal safety
Crisis support
Support for activities of daily living
PRIOR ADMISSIONS, CURRENT OUT-PATIENT SERVICES, ACTIVE SELF-HELP GROUPS
Please list any admissions to other psychiatric or addiction facilities:
Year admitted:
Facility:
Length of Stay:
Year admitted:
Facility:
Length of Stay:
Year admitted:
Facility:
Length of Stay:
Year admitted:
Facility:
Length of Stay:
Number of admissions to other facilities:
Are you currently using any out-patient services?
Yes
No If Yes, please provide details:
Name of Service:
Contact:
Telephone:
Name of Service:
Contact: __________________________________________________
Are you currently participating in any self-help groups?
Yes
Telephone: ____________________
No If Yes, please list:
_____________________________________________________________________________________________________________
PATIENT INFORMATION
1) Describe any difficulties in the following areas:
Difficulty with intense emotions:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Difficulties or lack of relationships
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Impulse Control Difficulties (e.g. High-risk sexual behaviours, shoplifting, etc.)
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
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Self-
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Self-harm previous
Yes
No If Yes, please describe:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Suicide behaviours current
Yes
No If Yes, please describe:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Suicide behaviours previous (if different from above)
Yes
No If Yes, please describe:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Involvement with the legal system
Yes
No If Yes, please describe:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
2) Past and Current Treatment
Please indicate what type of treatment you have received and if you found it helpful.
Individual Therapy or Counseling
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
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Group Therapy
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
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Self-Help
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Crisis Services/ER Visits
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
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_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
3. Medical Data
Please list any significant medical history including allergies, seizures, disabilities etc.
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Diet restrictions? (list allergies and intolerances)
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Are you pregnant?
Yes
No
Please list any allergies (e.g., medication, foods, insects): ________________________
Please indicate any religious beliefs or practices that may affect your treatment:
Do you smoke?
Yes
No
Date of last flu shot (YYYY-MM-DD):
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