Divide one page into six boxes: current symptoms, past symptoms, safety history, substance use, medications, and previous care. Under current symptoms, note changes in sleep, appetite, concentration, mood, fear, energy, perception, memory, or behavior. For each item, write when it started, whether it is constant or intermittent, what makes it worse, and how it affects daily tasks. Use your own words. A statement such as “I have slept about two hours a night for three nights and feel watched” gives a reviewer more usable information than “my mental health is bad.”
In the safety box, record any current or past thoughts of suicide, self-harm, harming someone else, severe confusion, seizures, falls, overdoses, or emergency visits. State what is happening now rather than burying urgent information in your history. If there is immediate danger, call 911. For crisis support, call or text 988, or use 988 chat. Do not treat Living Longer Recovery or another detox facility as emergency care unless that role has been independently established, which it has not been here. In the substance-use box, list each substance, typical amount, route, frequency, last use, and any recent change. Do not use this worksheet to create your own taper plan. Share it with a qualified professional.
- Symptoms in your own words, including when they began and whether they are happening now
- Sleep, eating, memory, perception, mood, and behavior changes
- Current and past safety concerns, overdoses, seizures, falls, or emergency visits if applicable without self-diagnosing their cause or significance, or omitting urgent information,