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Zumbro Valley Health Center
  • Mental Health
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      • ARMHS
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  • Mental Health
    • Adult Counseling
      • ARMHS
      • Substance Use & Recovery Services
    • Community Support
    • Depression & Anxiety Treatment
    • Integrative Healthcare & Wellbeing
    • Medication Management
    • Mobile Crisis & Stabilization
    • Residential Treatment Services
    • Support Groups
    • Telehealth
    • Veteran Services
    • Youth and Family Counseling
      • ADD/ADHD
      • Mood or Behavior Disorders
      • Trauma Treatment
      • Psychiatric Evaluation
      • School-Based Services
      • Substance Use & Recovery Services
  • Substance Use
    • Counseling
    • Detoxification
    • Drug Testing Services
    • DWI Education
    • Support Groups
  • Your Visit
    • What To Expect
    • About Us
    • Locations
    • Insurance Accepted
    • Client Forms
    • Make A Referral
  • Providers
    • Meet The Team
    • Leadership and Staff
    • Licensing and Certifications
  • Resources
    • Classes & Groups
    • Types of Therapy
    • Teachers & Parents
    • Educational Videos
    • ZVHC Videos
    • FAQs
    • News
    • Annual Report

Personal History Questionnaire

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  • Assessment Overview

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  • Mental Health History

  • Date of service:Where were you seen/treated:Focus of treatment: 
  • Name of medication:Dosage (if known):Reason for use (if known):Current or previous? 
  • Family History

  • Name/RelationshipAgeOccupationAlive? (yes/no) 
  • Name/RelationshipAgeOccupationAlive? (yes/no) 
  • Social/Relationship History

  • NameSexAgeLiving with you?Additional Information 
  • Education/Work History

  • Medical History

  • Name of medication:Dosage (if known):Reason for use (if known): 
  • Chemical Use History

  • Legal History

  • Coordination of Care

  • First Name:Last Name:Phone Number: 
  • This field is for validation purposes and should be left unchanged.

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Zumbro Valley Health Center

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  • Friday - 7:30am - 12:00pm
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© 2023 Zumbro Valley Health Center

Zumbro Valley Health Center