Skip to content
734-794-3777
|
RWCC@Refreshing-Waters.com
Facebook
LinkedIn
Twitter
Instagram
Search for:
Menu
Home
About Us
Our Team
Sheila Burns
Amber Cunnings
Kerry Basinger
Dr. Darren Jones
Our Services
ADHD Treatment
Alpha-Stim
Anger Management
Anxiety & Stress
Auricular/Ear Acupuncture
Career Counseling
Children
Adolescence
Christian Counseling
DBT
Depression
EFT
EMDR
Gender/Identity LGBT
Grief and Loss
Pre-Marital Counseling
Relationship Counseling
Substance Use/Addictions
Therapy
Trauma
Resources
Patient Reviews
Billing Information
Employment Opportunities
Our Office
FORM – Initial Assessment
Home
/
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
