Vanessa Levine-Smith
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about me
Vanessa Levine-Smith
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Personal
InformatioN
ID number received
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How is your general health?
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Which if any medications are you currently taking?
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Are you presently being treated for any physical or psychiatric condition?
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Please describe past psychiatric treatment, hospitalizations and diagnoses.
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Have you had any serious illness(es)? (List)
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How many hours of sleep do you get per night? (give range)
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How often do you exercise? (give range)
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Do you eat in secret?
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Do you eat large amounts of food in a brief amount of time?
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Please give quantities for your weekly substance use (including alcohol, CBD/marijuana, psychedelics, opioids, etc)
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Please list psychiatric diagnoses in your family.
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Who, if anyone, do you currently live with? (Please list first names only)
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Please note your age for any experiences you would describe as traumas. (Trauma includes emergency situations that you experienced directly or witnessed, as well as chronic relational neglect and abuse).
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Have you had any major losses over the past two years?
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Have you had any thoughts of hurting others, hurting yourself or ending your life?
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When was the last time you cut yourself, pulled out hair, or otherwise intentionally caused yourself physical pain?
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Please mark all that you are experiencing.
Anger
Anxiety
Behavior Problems
Changes in Appetite/Eating Habits
Criminal Activity
Decreased Energy
Depressed Mood
Disruption of Thought Process/Content
Emotional/Physical/Sexual Trauma
Frequent Crying
Family Conflicts
Feeling worthless
Grief
Guilt
Hallucinations (auditory and/or visual)
Hopelessness
Hyperactivity
Impulsiveness
Interpersonal Conflicts
Irritability
Mania
Mood Swings
Negative Thoughts
Numbness (emotional)
Panic Attacks
Paranoia
Physical Aggression
School/Work Problems
Self Harming
Sleep Disturbance
Somatic Complaints
Suicidal Thoughts/Attempt
Weight Gain
Weight Loss
Do you have trouble concentrating and/or keeping track of important items?
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Have you had any chronic, intense discomfort with sensory input (noises, textures), now or as a child?
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Do you experience unwanted thoughts, images or impulses that enter your mind, despite trying to get rid of them?
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What identities are most important to you?
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What do you value most in others?
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What do you value the most in yourself?
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How would you describe your religion/spirituality?
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What makes you feel strong, peaceful, or most alive?
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Please write anything else that may be important.
Thank you!