03008 Patient Information Form 2013-01-09

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:Alias:

Maiden Name:Gender:

Address: Transient

City:Province:Postal Code:Country:

Phone:Business Phone:Ext.Mobile Phone:

E-mail:Date of Birth:

Preferred Method of Contact: Phone E-mail
Health Card Number: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)

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Name:

Relationship to Patient:

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Address (if different from above):

City:

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Province/State:

Postal/Zip Code:

Country:

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Phone:

Business/Alternate Phone:

Email:

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SECOND EMERGENCY CONTACT INFORMATION (please provide telephone number(s) where messages can be left)

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Name:

Relationship to Patient:

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Address (if different from above):

City:

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Province/State:

Postal/Zip Code:

Country:

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Phone:

Business/Alternate Phone:

Email:

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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:

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City:

Province:

Postal:

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Phone:

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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: ______Telephone: ______

Are you currently participating in any self-help groups?  Yes  No If Yes, please list:

______

PATIENT INFORMATION

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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.)

______

Self-harm current  Yes  No If Yes, please describe:

______

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

______

Group Therapy

______

Self-Help

______

Crisis Services/ER Visits

______

3. Medical Data

Please list any significant medical history including allergies, seizures, disabilities etc.

______

Diet restrictions? (list allergies and intolerances)

______

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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):