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.

  • 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), and their diagnosis, along with all past and presently prescribed medications. If you do not know the diagnosis and the event occurred because of their mental illness, you can write “psychotic behavior.”

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. 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. If you have more information than one page, then write at 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.

This case example format is powerful. It is suggested that you print your case on colored paper if possible. Be sure to bold the EVENT and underline the diagnosis. Do not give details or state why the person was hospitalized as that information should be in the symptoms. Do not state that they were placed on a 5150, as that will be understood if they are in the psych hospital. Only list information of which you are aware. 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.  ​

The order: HOSPITALIZATION; Date to Present; Name of Hospital; Diagnosis, medications.


Example of a One-Page Mental Health History

Joe Doe’s Mental Health/Medical History

Hospitalized; January 1 to Present; Cedar Sinai Hospital, Los Angeles; Diagnosed: Schizophrenia

Hospitalized; December 12- 28, 2017; UCLA Harbor, Torrence: Diagnosed: and “Schizophrenia

Homeless; November 5- December 12, 2017; Venus area; Diagnosed: Exhibiting psychotic behaviors

Hospitalized; September 10- 23, 2017; College Hospital Long Beach;  Diagnosed: Bipolar

Incarcerated; March 2- April 4, 2017; Twin Towers; Diagnosed: psychotic behaviors

Homeless; January 3- March 1, 2017; Santa Monica; Diagnosis: Exhibiting psychotic behaviors

NOTE: Do not give Biaxin or Haldal; Has diabetes; Insurance Medi-Cal and receives SSI income