FORM – Initial Assessment

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FORM – Initial Assessment2020-04-20T13:57:55-04:00

Date*
Date Format: MM slash DD slash YYYY
First Name*
Last Name*
Age*
Date of Birth*
MM
DD
YYYY
Address*
City*
State*
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?*

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Ann Arbor, MI 48104
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