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Patient Enquiry

Family Information:*
Patient's Information:*
Medical Details:*
Previous treatments undergone:*
Current Psychiatric treatment*
Current Treatment For Chronic Disease (If any)*
Services Seeking:*
Services seeking from Adarsh Home:*
Desired Outcome:*
Desired outcome from treatment:*
Communication Preferences:*
Behavioral Information of the Patient:*
Psychological Assessment:*
Sensitive Information*
Lifestyle of the Patient:*
Treatment Preferences:*
Type of treatment desired:*
CASE HISTORY FORM AND TREATMENT PLAN
Living Arrangements:*
(I) FAMILY HISTORY-DETAILS REGARDING PARENTS AND SIBLINGS
In case of Death of parents (optional):
(II) CHILDHOOD AND ADOLESCENT HISTORY
Did you experience the following before the age of 15 years?*
(III) Had the Patient done these activities (BEFORE THE AGE OF 15 YEARS)
Had the Patient done these activities:*
(IV) MARITAL HISTORY (Optional)
Details regarding spouse
Is this marriage arranged or by choice?
Details regarding previous or subsequent marriages, If any
Any Instance of family violence? Yes, give details
Details regarding children
Health Status of the Family
Family damage as seen by the counselor
(V) Sexual History(Optional)
Record extra marital or, pre-marital experiences) If present,
Any children
Have you been involved in any high-risk sexual activities?
Have you been tested for HIV?
(VI) OCCUPATIONAL HISTORY (Optional)
Financial damage as perceived by a counsellor
(VII) LEGAL HISTORY

Have you got into trouble with the law for the following? If Yes

(VIII) LEISURE TIME ACTIVITIES
(IX) RELIGIOUS BELIEFS
Are you a :*
Do you :*
Additional Information*