Here are directions for writing a one-page mental health history, which is recommended for family members of those with mental health conditions. This one-page summary of the patient’s history with mental illness can be provided to doctors or law officers when there is a crisis. If you can, print it on brightly colored paper. Note: You are not expected to have access to all of your relative’s medical history; if you are missing information, simply do the best you can. 

Instructions for writing the one-page mental health history of your loved one:

  • Include your loved one’s name, age and insurance information on top. Note their insurances, such as Medi-Cal, Medicare, or private insurance. (They can have all three.) Note what financial resources they receive, such as SSI, SSDI, or Social Security. (Do not include their social security number.)
  • Note your loved one’s diagnosis. If you do not know the diagnosis and the event occurred because of their mental illness, you can write “psychotic behavior.”
  • List your loved one’s symptoms.
  • List your loved one’s medications and other drug use, including overdoses.
  • In chronological order, starting with the most recent event, list your loved one’s history of hospitalizations, incarcerations, homelessness and any restraining orders that may have been required.
  • Write the approximate date(s) as best you can recall, the facilities where they have been placed (or, if homeless, the general area if it is known).
  • Note any allergies your loved one may have.

Limit this information to only one page. Allow space at the bottom of the page to note any allergies, medical problems, or medicines they should not have.

If you have more information and it won’t fit on one page, then include on the bottom of the page that they have been ill since the age of ___, and/or that they have had ___ amount of previous hospitalizations, incarcerations, homeless situations.