Dr Melane van Zyl Practice - Dr Melane Van Zyl | Psychiatrist & Psychotherapist South Africa

Adolescent DBT Patient Intake Form (#33)

ADOLESCENT DBT - 16 WEEK PROGRAM

PARTICIPANT INFORMATION

First Name

Last Name

Date of birth

Parent/ Guardian Email

Patient Gender

Patient Age

Contact no.

Parent/ Guardian Contact no.

DSM-V Diagnosis: (if you are aware of it)

Current Employment Status

Student

At home

Medical Aid

Medical Aid Option

Membership Number

YOUR TREATING THERAPISTS' DETAILS

Who is your treating psychiatrist?

Where is your psychiatrist located?

Contact details of treating psychiatrist:

Who is your psychologist?

Where is your psychologist located?

Contact details of psychologist:

Who is your GP?

Where is your GP located?

Contact details of GP:

CLINICAL NOTES

What is your main reason for participating in the DBT program?

Can you attend the weekly sessions and do short daily practices?

Yes

How many episodes of depression have you had in your life?

One

Two

Three

More than three

Have you ever been admitted to a hospital or clinic for depression?

Yes

How many times?

Once

Twice

More than twice

When was your last admission?

Have you engaged in self-harm in the last three months?

Yes

Please specify:

Do you use any substances?

Yes

Please specify:

Have you ever had a psychotic episode?

Yes

Please specify:

Have you been diagnosed with PTSD (Post-Traumatic Stress Disorder) or experienced a traumatic event?

Yes

Please specify:

Do you have any illnesses that cause problems with breathing, or do you have chronic pain?

Yes

Please specify:

Will you be seeing your therapist for the duration of the program?

Yes

TREATMENT PLAN

The purpose of the DBT program is to teach you new skills on how to manage the symptoms of depression. However, the skills trainers are not responsible for your treatment. Therefore, you must have a treating therapist/doctor and an emergency management plan.

Yes, I agree

PAYMENT PLAN

We will contract a payment plan with you. Please email us for information regarding the different payment options.

Yes, I agree

For any queries, please email us at info@drmelanevanzyl.com.

error: Content is protected !!