Clone of BMHC Medical History Form

To the GP: please include in your referral letter the reason for referral and a specific clinical question, relevant medical history and recent blood test results, current medication and dosages, and previous treatments and their effects.

Psychotherapy prescription vs. one-time psychiatric evaluation

Insurance confirmation

Family doctor referral letter (mandatory, other documents will not be accepted⚠️)

Please upload your referral letter before continuing.

Patient Full Name

First NameLast Name

Patient Mobile Phone Number

Country CodePhone Number

Emergency Contact

Provide Name, Phone Number and Relationship

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Belgian Social Security Number

Required for electronic medical record and prescriptionsFormat: 00-00-00-000.00.

E-mail

example@example.com

Purpose of current visit

Current Family Doctor

Current Psychologist

If applicable

Current Medication

Provide dosage, time, starting date

Current Substance Use

When present, please specify quantity and duration of use

Prior treatments with a psychiatrist or psychotherapist

Please provide in chronological order

Prior Psychiatric Hospitalisations

Prior Psychiatric Medications

Please specify treatment, dosage, duration and effects/side-effects

Medical history

Do you have any medication allergies or other allergies?

History of traumatic life-events

Family History of Mental Health Symptoms

If applicable: please specify family member and treatment

One-time Psychiatric Intake Form

CURRENT COMPLAINTS

Please indicate if you've been experiencing the following symptoms recently

HISTORY