Jeanne Holverstott, MS
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Have you taken medications for your mental health? If so, please provide the following information: 1. Medication, 2. Dates taken, 3. Reason taken, 4. Prescriber, 4. Reason discontinued, if applicable.
Have you worked with any therapists (psychologist, social worker, counselor)? If so, please provide the following information: 1. Name of therapist, 2. Dates of treatment, 3. Reason for treatment, 4. Reason treatment ended.
Have you been hospitalized for your mental health? If so, please provide the following information: 1. Dates of hospitalization, 2. Location of hospitalization, 3. Reason for hospitalization, 4. Medications upon discharge, 5. Follow-up treatment following discharge.
Jeanne Holverstott, MS
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