Patient Condition Form (Initial Admission Form) 📢 اگر فارسی زبان هستید، فرم شرح حال بیمار فارسی را تکمیل نمایید Patient Condition Form ▪️ Personal Information NameLast NameContact NumberReferrer / How did you hear about usAgePlace of ResidenceEducationOccupationMarital Status Single Married Divorced Widowed In a Relationship ▪️ Family InformationFather's age (if deceased, age at death)Father's EducationFather's OccupationFather's Living Status Alive DeceasedIf he deceased, how many years agoMother's age (if deceased, age at death)Mother's EducationMother's OccupationMother's Living Status Alive DeceasedIf she deceased, how many years ago ▪️ Siblings' information Write the information of each of your siblings on a separate line (Example: Sister's name / Brother's name - Age - Occupation - Education ) ▪️ Problem Description and History(? Chief Complaint) : «Please explain the main reason or concern for which you are seeking counseling.»(? Onset) : «?When did these issues begin»(? Why now) : «What event, change, or pressure led you to seek counseling at this time» ▪️ Treatment and Medication HistoryHistory of Psychological or Psychiatric Treatment : «Have you ever received counseling, psychotherapy, or medication treatment? If yes, please explain (duration, type of treatment, outcome, reason for termination) »Previously Used Medications :Current Medications : ▪️ Smoking, Alcohol, and Substance Use? Do you currently smoke Yes No? Have you smoked in the past Yes NoIf yes, please describe the amount and duration :? Do you currently consume alcohol Yes No? Have you consumed alcohol in the past Yes NoIf yes, please describe the amount and duration :? Do you currently misuse substances Yes No? Have you misused substances in the past Yes NoIf yes, please specify the type of substance(s), amount, and duration ▪️ Conditions for Attending Sessions Time Availability for In-Person or Online Sessions: «On which days and times are you available to attend sessions»Financial Limitations for Paying Each Session: «Considering that sessions are held weekly, what amount can you pay per session?»Submit
