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Log of Mental Health Treatment
Patient's name: ________________________________________________________________
Form completed by: _____________________________________________________________
Relationship to patient: _______________________________________________________
Date:___________________________________________________________________________
Psychiatric Medications
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Dates that patient
took medication
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Name of the
medication
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Dosage
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Doctor
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What symptoms
did
the drug help?
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Side effects
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Was it taken
as prescribed?
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1/99 - present
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Zoloft
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100mg
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Masters
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Better mood, less
crying, slept better
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some headaches,
but went away
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95% of the time
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Psychiatric Admissions / Substance Abuse
Treatment Programs
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Dates
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Name of hospital
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Doctor
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Reason for admission
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Diagnosis(es)
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3/5/00 - 3/15/00
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OKC VA Medical Center
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Warren
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thoughts of killing
himself after his dad's death
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Major Depressive
Disorder
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1/90 - 2/90
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St. Anthony's Hospital
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Harding
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heavy alcohol use
& a 2nd DUI
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Alcohol Abuse, Depression
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Psychotherapy or Classes
| Dates |
Type of service |
Provider
(credentials) |
Frequency |
Issues addressed |
| 6/99 - 8/99 |
Depression
Class |
Morgan, Ph.D. |
once/week |
changing
negative thought patterns |
| 2/99 - 3/99 |
Individual
therapy |
Smith, MSW |
2x/month |
low self-esteem;
family problems |
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Patient's Current Physical Health Problems
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