SELF INFORMATION FORM

SELKIRK MENTAL HEALTH CENTRE

You have been referred to the Dialectic Behaviour Therapy Program. We need some information from you to ensure our
program will meet your needs. If you are unable to complete this form by yourself, you can ask a friend or relative to help
you complete it or you may contact us toll free 1-800-881-3073 extension 618 (Dr. Holm) or extension 676 (Lynn Luining).

Please complete this form in black ink and return it to: Young Building
Acute Program Manager
Selkirk Mental Health Centre
Box 9600
SELKIRK MB R1A 2B5
Fax: (204) 482-6390
CONTACT INFORMATION (please provide telephone number(s) where messages can be left)

Title: Last Name: Given Name:

Preferred Name: Middle Name: Alias:

Maiden Name: Gender:

Address: Transient

City: Province: Postal Code: Country:

Phone: Business Phone: Ext. Mobile Phone:

E-mail: Date of Birth:

Preferred Method of Contact: Phone E-mail

Health Card Number: Issuing Province:

Health Card Name (if different from above): OR Reason for No Health Card #:

EMERGENCY CONTACT INFORMATION (please provide telephone number(s) where messages can be left)

Name: Relationship to Patient:

Address (if different from above): City:

Province/State: Postal/Zip Code: Country:

Phone: Business/Alternate Phone: Email:

SECOND EMERGENCY CONTACT INFORMATION (please provide telephone number(s) where messages can be left)

Name: Relationship to Patient:

Address (if different from above): City:

Province/State: Postal/Zip Code: Country:

Phone: Business/Alternate Phone: Email:

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PHARMACY INFORMATION
Are you currently taking any prescription or over the counter medications?
Please list the medication and when you are taking it:
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Pharmacy Name: Address:

City: Province: Postal:

Phone:

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DISCHARGE PLANNING

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After discharge, would you have concerns about any of the following? (check all that apply)

Child care issues Personal safety Crisis support Support for activities of daily living

PRIOR ADMISSIONS, CURRENT OUT-PATIENT SERVICES, ACTIVE SELF-HELP GROUPS

Please list any admissions to other psychiatric or addiction facilities:

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Year admitted: Facility: Length of Stay:

Year admitted: Facility: Length of Stay:

Year admitted: Facility: Length of Stay:

Year admitted: Facility: Length of Stay:

Number of admissions to other facilities:

Are you currently using any out-patient services? Yes No If Yes, please provide details:

Name of Service:

Contact: Telephone:

Name of Service:

Contact: __________________________________________________ Telephone: ____________________

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Are you currently participating in any self-help groups? Yes No If Yes, please list:
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PATIENT INFORMATION

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1) Describe any difficulties in the following areas:

Difficulty with intense emotions:

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Difficulties or lack of relationships

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Impulse Control Difficulties (e.g. High-risk sexual behaviours, shoplifting, etc.)

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Self-harm current Yes No If Yes, please describe:

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Self-harm previous Yes No If Yes, please describe:

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Suicide behaviours current Yes No If Yes, please describe:

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Suicide behaviours previous (if different from above) Yes No If Yes, please describe:
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Involvement with the legal system Yes No If Yes, please describe:

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2) Past and Current Treatment

Please indicate what type of treatment you have received and if you found it helpful.
Individual Therapy or Counseling
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Group Therapy
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Self-Help
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Crisis Services/ER Visits
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3. Medical Data

Please list any significant medical history including allergies, seizures, disabilities etc.
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Diet restrictions? (list allergies and intolerances)

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Are you pregnant? Yes No Please list any allergies (e.g., medication, foods, insects): ________________________

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Please indicate any religious beliefs or practices that may affect your treatment:

Do you smoke? Yes No Date of last flu shot (YYYY-MM-DD):

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