Self Information Form Selkirk Mental Health Centre

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:
Page 1 of 11
PHARMACY INFORMATION
Are you currently taking any prescription or over the counter medications?
Please list the medication and when you are taking it:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Pharmacy Name: Address:
City: Province: Postal:
Phone:
Page 3 of 11
DISCHARGE PLANNING
Page 4 of
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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:
Page 5 of
3
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: ____________________
Page 6 of
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Are you currently participating in any self-help groups? Yes No If Yes, please list:
_____________________________________________________________________________________________________________
PATIENT INFORMATION
Page 7 of 11
1) Describe any difficulties in the following areas:
Difficulty with intense emotions:

_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Difficulties or lack of relationships

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

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

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

_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Suicide behaviours current Yes No If Yes, please describe:

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

_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
2) Past and Current Treatment
Please indicate what type of treatment you have received and if you found it helpful.
Individual Therapy or Counseling
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Page 8 of 11
Group Therapy
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Self-Help
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Crisis Services/ER Visits
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
3. Medical Data
Please list any significant medical history including allergies, seizures, disabilities etc.
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Diet restrictions? (list allergies and intolerances)

_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Page 9 of 11
Are you pregnant? Yes No Please list any allergies (e.g., medication, foods, insects): ________________________
Page 10 of
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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):
Page 11 of
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SELF INFORMATION FORM

SELKIRK MENTAL HEALTH CENTRE

Title: Last Name: Given Name:

Preferred Name: Middle Name: Alias:

Maiden Name: Gender:

City: Province: Postal Code: Country:

Phone: Business Phone: Ext. Mobile Phone:

E-mail: Date of Birth:

Preferred Method of Contact: Phone E-mail

Name: Relationship to Patient:

Province/State: Postal/Zip Code: Country:

Phone: Business/Alternate Phone: Email:

Name: Relationship to Patient:

Address (if different from above): City:

Province/State: Postal/Zip Code: Country:

Phone: Business/Alternate Phone: Email:

Pharmacy Name: Address:

City: Province: Postal:

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

Year admitted: Facility: Length of Stay:

Year admitted: Facility: Length of Stay:

Year admitted: Facility: Length of Stay:

Number of admissions to other facilities:

Contact: __________________________________________________ Telephone: ____________________

Difficulty with intense emotions:

Difficulties or lack of relationships

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

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

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

Suicide behaviours current Yes No If Yes, please describe:

Involvement with the legal system Yes No If Yes, please describe:

2) Past and Current Treatment

Diet restrictions? (list allergies and intolerances)

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

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