New Adult Evaluation

Date:

Patient Name:*

DOB:

Referred by:

Name of person completing this form if not patient:

Briefly describe the events that led to this appointment:

0/1000

Have there been any previous mental health contacts? If yes, list these contacts and approximate dates of treatment:

0/500

Use the scale below to rate the occurrence of each of the following. Provide any comments in the space provided.

1= None or little of the time, 2 = Some of the time, 3 = Most of the time, 4 = All of the time.

During the past week, I

	1	2	3	4
Felt low in energy or slowed down
Blamed myself for things going bad
Felt hopeless
Felt blue or sad
Felt worthless
Had trouble falling asleep, staying asleep or sleeping too much
Had trouble concentrating or making decisions
Had thoughts about suicide
Had thoughts of harming others
Felt irritable
Had racing thoughts
Was hyperactive or impulsive
Found my appetite increased or decreased
Had crying spells
Was not motivated
Had no interest in doing anything
Had thoughts or did cutting or self-harm
Felt overly happy or full of confidence

Any comments about the section above:

0/500

Use the same scale to rate the occurrence of each of the following:

During the past week, I

	1	2	3	4
Felt moments of fear
Felt anxious, worried, or nervous
Felt the worst things were going to happen
Felt sweaty, heart pounding, tight breathing
Felt afraid of losing control
Sought reassurance from others due to worry
Felt tense, edgy, restless, or unable to relax
Was unable to make decisions
Avoided situations because of feeling nervous
Feared being rejected, humiliated, embarrassed, or ridiculed by others
Avoided social situations because I was afraid of embarrassing myself
Had attacks of anxiety or panic
Had periods of stuck thoughts or behaviors
Had uncomfortable or intrusive thoughts
Restricted food intake
Exercised excessively
Had episodes of bingeing or purging
Was afraid of driving or leaving home
Found it hard to trust people
Was overly angry or aggressive

Any comments about the section above:

0/500

Use the same scale to rate the occurrence of each of the following:

During the past week, I

	1	2	3	4
Had ''flashbacks'' or a sense reexperiencing an old event
Felt numb or empty thinking about or being triggered by an old event
Felt overwhelmed, agitated, or upset thinking about or being triggered by an old event
Felt ''super alert,'' on guard, or constantly on the lookout for danger
Was easily startled by unexpected noise

Any comments about the section above

0/500

Have you ever been a victim or offender of abuse or trauma?

Emotional:

YesNo

Sexual:

YesNo

Physical

YesNo

Any comments about the section above:

0/450

Use the table below to list the people in your current living situation:

	Name	Relation to Yourself	Age	Education/ Occupation
1.
2.
3.
4.
5.

Any comments about the family life, relationships, or people identified above

0/450

Do any of the people listed above have a mental health, alcohol or drug problem? If yes, please describe.

0/450

Describe your current employment and financial situation:

0/450

Describe any relevant legal issues:

0/450

Describe any other relevant stressors:

0/450

Use the table below to list your parents, siblings, or other people who lived with you growing up:

	Name	Relation to Yourself	Age	Education/ Occupation
1.
2.
3.
4.
5.

Any comments about the family life, relationships, or people identified above:

0/450

Do any of the people listed above have a history of mental health, alcohol, or drug problems? If yes, please describe.

0/500

Who is your Primary Care Doctor?

Date of your most recent visit:

Any medical issues, past or present, relevant to treatment:

0/450

List all current medications:

0/300

Allergies (include medication allergies):

0/300

Please complete the following table and answer the questions below. Add comments if necessary:

Substance Use:

	Age @ First Use	Use Last 30 Days	Average Quantity Per Use	Last Used	Amount Used
Alcohol
Sedatives/ Barbituates
Heroin (Opioids)
Cocaine
Other Stimulants
Marijuana
Hallucinagenics

Someone in the biological family has or has had a serious substance abuse problem.

YesNo

In the past two years, there has been one or more episodes of memory loss due to substance abuse.

YesNo

There are personality changes due to the use of substances.

YesNo

In the past 5 years, there has been one or more arrest with a B.A.L. of .16% or higher.

YesNo

Someone close to you thinks you may have a serious substance use problem.

YesNo

In the past year there has been an out of control experience due to substance use.

YesNo

There is a history of serious problems with the use of substances.

YesNo

There is a history of substance abuse treatment may include 12-step program.

YesNo

Any comments about the section above:

0/400

ADULT INITIAL EVALUATION