If your client has a history of depression, please answer the following :


      Agent Name:  



   Client Name: 



   Phone:  



   Fax: 
   


   1.  Diagnosis ? 


   2.  Number of episodes ? 

       Date of last episode/recovery ? 


   3.  Is your client on any medication ? Yes   No 

       If yes, give details: 


   4.  Has your client been hospiltalized for treatment of depression ? Yes   No 

       If yes, give details: 


   5.  Has your client received ECT ("Shock Treatment") ? Yes   No 

       If yes, give details: 


   6.  Does your client have a history of any of the following associated conditions ?
        Substance Abuse (alcohol or drugs)
        Personality Disorder
        Psychotic Disorder
        Suicidal Thought/Attempt



   7.  Has your client smoked cigarettes in the last 12 months ? Yes   No 


   8.  Does your client have any major health problems ? Yes   No 

       (example: cancer, etc.)

       If yes, give details: