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
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Impulse Control Difficulties (e.g. High-risk sexual behaviours, shoplifting, etc.)
______
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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
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Group Therapy
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Self-Help
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Crisis Services/ER Visits
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3. Medical Data
Please list any significant medical history including allergies, seizures, disabilities etc.
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______
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):