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BEHAVIORAL HEALTH INFORMATION

Client Name:

Options Location:

What services are you seeking? Therapy Med Management Skills Training

What is the main reason you’re seeking services at this time?

Please mark any concerns you or your child have in the following areas. (Select only those that apply to the client).
sad, depressed cry easily mood swings can’t sleep sleeping too much tired often muscle tension can’t eat eating too much feel anxious, nervous panic/anxiety attacks often fearful, afraid easily startled feel overwhelmed worry often feel stressed feel worthless easily angered aggression irritability obsessive behaviors self harm behaviors thoughts of suicide nightmares flashbacks can’t remember things can’t concentrate hyperactivity problems learning hearing voices seeing things that are not there alcohol/drug use

The following symptoms affect or may be affected by your (or your child’s) behavioral health needs. Please check if any of the following are currently affecting your life.
moving housing concerns homeless job loss death/grief concerns about children child with special needs abuse in family domestic violence alcohol/drugs in family concerns about a parent family conflicts divorce relationship concerns pregnancy physical health concerns legal issues/criminal record

Are you (or your child) currently taking any medications?

Yes

If yes, what?

Other concerns or issues:

Client Name :

Relation to Client : SelfParent / GuardianLegal CustodianGuardianOther, as listed

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Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

May 11, 2020 9:20 am PST

BEHAVIORAL HEALTH INFORMATION Uploaded by Adam Falk - adam.falk@options.org IP 69.1.101.108

May 11, 2020 9:36 am PST

Options Records - OCFSrecords@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195

May 20, 2020 8:07 am PST

Options Records - OCFSrecords@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195

May 20, 2020 8:11 am PST

Options Records - OCFSrecords@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195

May 20, 2020 8:11 am PST

Options Records - OCFSrecords@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195

October 27, 2020 10:44 am PST

Options Records - OCFSrecords@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 108.174.191.234

October 28, 2020 8:12 am PST

Options Records - OCFSrecords@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 108.174.191.234

October 30, 2020 10:36 am PST

Options Intake - intake@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 108.174.191.234

September 29, 2021 1:21 pm PST

Options Intake - intake@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 206.192.252.48

November 19, 2021 10:01 am PST

Options Intake - intake@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 206.192.255.82

November 19, 2021 10:09 am PST

Options Intake - intake@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 206.192.255.82

November 19, 2021 10:09 am PST

Options Intake - intake@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 206.192.255.82