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Sheila Burns
Alexandria Betke
Tiffany Gillette
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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
*
