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FORM – Initial Assessment
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FORM – Initial Assessment
FORM – Initial Assessment
2020-04-20T13:57:55-04:00
Date
*
Date Format: MM slash DD slash YYYY
First Name
*
Last Name
*
Age
*
Date of Birth
*
MM
DD
YYYY
Address
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Zip Code
*
Primary Phone Number
*
Secondary Phone Number
May we leave a message?
*
Yes
No
Email
*
Emergency Contact Info
Emergency Contact Name
*
Emergency Contact Phone
*
Emergency Contact Relationship
*
Reason for Visit
What brings you to counseling and how long has it been a concern?
*
Current Diagnosis
Previous Treatment
I Have...
Memory Problems
*
Yes
No
If yes, for how long?
Trouble explaining myself to others
*
Yes
No
If yes, for how long?
Problems understanding what others tell me
*
Yes
No
If yes, for how long?
Intrusive or strange thoughts
*
Yes
No
If yes, for how long?
Obsessive thoughts
*
Yes
No
If yes, for how long?
Been hearing voices
*
Yes
No
If yes, for how long?
Problems with my speech
*
Yes
No
If yes, for how long?
I Have...
Risk-taking behavior
*
Yes
No
If yes, for how long?
Compulsive or repetitive behaviors
*
Yes
No
If yes, for how long?
Been acting without concern for consequence
*
Yes
No
If yes, for how long?
Been physically harming myself
*
Yes
No
If yes, for how long?
Been violent toward others
*
Yes
No
If yes, for how long?
I am Experiencing...
Frequent worry or tension
*
Yes
No
If yes, for how long?
Fear of many things
*
Yes
No
If yes, for how long?
Discomfort in social situations
*
Yes
No
If yes, for how long?
Feelings of guilt
*
Yes
No
If yes, for how long?
Phobias: unusual fears about specific things
*
Yes
No
If yes, for how long?
Panic attacks: sweating, trembling, shortness of breath, heart palpitations
*
Yes
No
If yes, for how long?
Recurring, distressing thoughts about a trauma
*
Yes
No
If yes, for how long?
Flashbacks as if reliving the traumatic event
*
Yes
No
If yes, for how long?
Avoiding people/places associated with trauma
*
Yes
No
If yes, for how long?
Nightmares
*
Yes
No
If yes, for how long?
I am Feeling...
Decreased interest in pleasurable activities
*
Yes
No
If yes, for how long?
Social isolation, loneliness
*
Yes
No
If yes, for how long?
Suicidal thoughts
*
No Suicidal Thoughts
Past Suicidal thoughts
Current Suicidal thoughts
Past suicidal attempts
If yes, for how long?
Bereavement or feeling of loss
*
Yes
No
If yes, for how long?
Changes in sleep (too much or not enough)
*
Yes
No
If yes, for how long?
Normal, daily tasks require more effort
*
Yes
No
If yes, for how long?
Sad, hopeless about future
*
Yes
No
If yes, for how long?
Excessive feelings of guilt
*
Yes
No
If yes, for how long?
Low self-esteem
*
Yes
No
If yes, for how long?
I Notice...
I am angry, irritable, hostile
*
Yes
No
If yes, for how long?
I feel euphoric, energized, and highly optimistic
*
Yes
No
If yes, for how long?
I have racing thoughts
*
Yes
No
If yes, for how long?
I need less sleep than usual
*
Yes
No
If yes, for how long?
I am more talkative
*
Yes
No
If yes, for how long?
My moods fluctuate: go up and down
*
Yes
No
If yes, for how long?
Marital Status / Living Arrangement
Marital Status / Living Arrangement
*
Single
Married
Divorced
Cohabitating
Roommates
Parents
School
Who lives in your residence?
*
Please describe your current family relationships
*
Primary Care Physician Name
Primary Care Physician Phone
Psychiatrist Name
Psychiatrist Phone
Please list any medical conditions
Current medications and supplements
Most recent physical
How is your overall health
My Eating Involves...
Restrictions of food consumption
*
Yes
No
If yes, for how long?
Binging and purging
*
Yes
No
If yes, for how long?
Binge eating
*
Yes
No
If yes, for how long?
Weight loss or gain
*
Yes
No
If yes, for how long?
I Have...
Concern about my sexual function
*
Yes
No
If yes, for how long?
Discomfort engaging in sexual activity
*
Yes
No
If yes, for how long?
Questions about my sexual orientation
*
Yes
No
If yes, for how long?
I use the following...
Alcohol
*
Yes
No
If yes, for how long?
Nicotine (cigarettes or chewing tobacco)
*
Yes
No
If yes, for how long?
Marijuana
*
Yes
No
If yes, for how long?
Cocaine
*
Yes
No
If yes, for how long?
Opiates
*
Yes
No
If yes, for how long?
Sedatives
*
Yes
No
If yes, for how long?
Hallucinogens
*
Yes
No
If yes, for how long?
Stimulants
*
Yes
No
If yes, for how long?
Methamphetamines
*
Yes
No
If yes, for how long?
Please describe your substance use
Personal and Family History
Have you or a close relative ever been hospitalized for psychiatric illness?
*
Yes
No
If yes, for how long?
Does anyone in your family have mental illness?
*
Yes
No
If yes, for how long?
Has anyone in your family ever attempted or completed suicide?
*
Yes
No
If yes, for how long?
Does anyone in your family have substance abuse?
*
Yes
No
If yes, for how long?
Do you have any history of neglect, abuse, or trauma?
*
What are your spiritual beliefs/practices?
*
Are you in school? Please explain
*
Are you employed? Please explain
*
What do you do for social engagement?
*
Have you ever been arrested? Please explain
*
Do you have any current financial stressors?
*
What are your strengths/abilities?
*