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Do any immediate or extended family members suffer from mental health issues, such as: depression, anxiety, bipolar, etc.? No Yes

Has applicant ever engaged in isolating behaviors?

What is your reason for seeking placement at Bridge House (Please be very specific including issues at home and work as well as any symptoms such as mood changes, etc.):

What specific events precipitated the decision to seek treatment

What are your specific goals regarding treatment?

What are the applicant's strengths (intellectually, artistically, socially, physically, etc.):

What are the applicant's weakness (intellectually, artistically, socially, physically, etc.):

Describe the applicant's experience with the outdoors and other physical activities:

Describe any major events the applicant has struggled with (divorce, moving, birth of child, loss, death, abuse, illness, etc.), including the date the event occurred:

Describe the way(s) in which the applicant expresses anger:

Has the applicant ever had thoughts of suicide, made a plan, or attempted suicide? No Yes

Has applicant ever experienced signs or symptoms of anxiety, depression, mood swings, etc.? No Yes

Has applicant ever experienced recurrent thoughts or repeated behaviors that he/she cannot control?

Does the applicant have any alcohol, tobacco, or other substance and/or dependency related issues?

Alcohol and drug use/abuse, route of ingestion, related physical and/or emotional consequences of use, and past and/or current withdrawal
If Yes, provide details, incl. age of first use, substance, usage patterns/frequency/administration:
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Regards; Team

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