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Reed J. Robinson, Ph.D., ABPP, MBA

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Mental Health History (Continued)

Patient Name*

Therapy History

Have you engaged in therapy before?

Yes

No

Risk Assessment

Have you ever had thoughts of harming yourself?

Yes

No

Do you have thoughts of harming others?

Yes

No

Substance Use History

Do you currently use any of the following substances?*

Alcohol

Marijuana (including THC gummies; Delta 8; or other synthetic formulations of THC)

Cocaine (snorted)

Crack Cocaine (smoked)

Methamphetamine

Other Speed or other "Uppers"

Heroin

Opiate Medication

Xanax, Qualudes, or other "Downers"

Mushrooms, LSD, or other Psychadelics

Yes, other substance

No, I do not use alcohol or recreational drugs

I prefer not to say

Continue to Symptoms Assessment (Recommended)

© 2024 by Dr. Reed J. Robinson, Ph.D., ABPP, MBA

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