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PRIOR MENTAL HEALTH INFORMATION

Patient Name: _____________________________________________________

 No prior mental health services

Provider/Facility Name: ______________________________________________
Address: __________________________________________________________
City/State/Zip: _____________________________________________________
Phone: ____________________________ Fax: _______________________

Permission to obtain records:  Yes  No

Provider/Facility Name: ______________________________________________
Address: __________________________________________________________
City/State/Zip: _____________________________________________________
Phone: ____________________________ Fax: _______________________

Permission to obtain records:  Yes  No

Provider/Facility Name: ______________________________________________
Address: __________________________________________________________
City/State/Zip: _____________________________________________________
Phone: ____________________________ Fax: _______________________

Permission to obtain records:  Yes  No

Provider/Facility Name: ______________________________________________
Address: __________________________________________________________
City/State/Zip: _____________________________________________________
Phone: ____________________________ Fax: _______________________

Permission to obtain records:  Yes  No

_______________________ ________________________________
Date                                        Signature