| Referral Reason & Presenting Situation |
| Include details of the presenting situation and current functioning as described by the client, the referral source, family or others concerned. |
| History of Presenting Situation/History of Presenting Illness |
| Include a description of the onset and development of the presenting problems, fluctuations in their severity and their impact on the individual’s life and environment. Identify collateral information as such. |
| Physical & Medical History |
| Include past and current physical, medical, surgical, and obstetrical history (as applicable), accidents (including brain injuries), seizures, and any relevant lab work, tests/scans, from childhood to adulthood. |
| Medications |
| List current medications including OTC and relevant vitamins and herbs. |
| Psychiatric History/Mental Health History |
| Include a description of past psychiatric illness including hospitalizations and other past treatment and support (e.g. past medication trials, neurostimulation, and other therapies). |
| Substance Use, Treatment & Supports |
| Include substance use comments and past and current treatment such as opioid replacement therapy, withdrawal management, harm reduction, individual, group, peer supports, treatment programs, support recovery, and specialized supports. |
| Family Medical & Psychiatric History |
| Include family medical, psychiatric history and relevant family substance use history. |
| Personal & Social History |
| Include personal history (family background and strengths) and current psychosocial factors (e.g. activities of daily living, housing, finances/income, education/work, community supports, cultural identity and spirituality, gender identity and expression, sexual orientation and relationship status. |
| Legal History |
| Include current and past legal issues, involvement with law enforcement, formal financial and health care decision makers and documents (e.g. representation agreements, power of attorney, wills). Include any representatives in the Unregistered Contacts grid. |
| Mental Status |
| Include appearance, attitude, behaviour, mood and affect, speech, thought process, thought content, perceptions (e.g. hallucinations), cognition (e.g. alertness, orientation, attention, concentration, visuospatial, language and executive functions), insight and judgement. |
| Risks |
| Include risks (e.g. harm to others, self-harm, suicidality, harm by others, child protection, violence in relationships) and severity (e.g. current ideation, intent, plan, approximate dates of previous attempts, and information regarding lethality of attempts). |