Clinical Assessment Form

Clinical Assessment Form
Name
First NameLast Name
Date
MonthDayYear
Date
Date of Birth
MonthDayYear
Date
Age
Status
Spouse's Information
Name of Spouse
First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Alternative Phone Number (if any)
Please enter a valid phone number.Format: (000) 000-0000.
Personal Information
Home Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name of Referrer
PrefixFirst NameLast Name
Health Assessment
Chief Concern
Please indicate how long you have been having the condition
Do you currently have any other known medical problems?
Please explain
Please indicate how long you have been having the condition
Have you ever been treated for any of the following?
Other
Please explain
Have you previously seen a therapist or psychiatrist?
Please explain
Have you ever been hospitalized for medical or mental illness?
Please explain
Indicate when, where, and reason
Are you currently taking any prescription medications?
Please indicate the names and dosage
Have you previously taken any prescription medications?
Please indicate (names, dosage, when)
Do you drink alcohol or use recreational drugs?
Please indicate the kind and frequency
Name Of Your Primary Care Physician
PrefixFirst NameLast NameSuffix
Name Of Psychiatrist/Psychologist (if applicable)
PrefixFirst NameLast NameSuffix
Date of Last Complete Physical Examination
MonthDayYear
Date
What type of food do you regularly eat?
How frequent do you exercise and how long?
Family Information and Social Relationships
Family Relations
Rows Father Mother
Age (if deceased, please indicate age, date of death, and cause of death)
Country of Origin
Describe your relationship
Were you adopted?
Number of Years Your Parents Married
Are They Divorced?
How Old Were You When They Divorced?
Have had family difficulties during growing up?
Please describe
Siblings
Children

Rows	Father	Mother
Age (if deceased, please indicate age, date of death, and cause of death)
Country of Origin
Describe your relationship

Struggles During Childhood:

Rows	Yes	No	Age	Brief Description
Learning Difficulty
Hyperactivity
Fears in School
Experienced Being Bullied
Eating Disorders
Witnessing Violence at Home
Experienced Sexual, Physical or Emotional Abuse

Family Mental Health

Rows	Yes	No	Relationship
Anxiety Disorder
Bipolar or Mood Disorder
Depression
Domestic Violence
Eating Disorders
Excessive Alcoholism
Obsessive-Compulsive Behavior
Suicidal
Substance Abuse
Schizophrenia
Undergone Counseling or Psychotherapy

Are you living in with a partner?
Are there any concerns about your current relationship that you would like to discuss?
Please describe your current custody & visitation schedule (if any) and the status of your communication:
Please describe briefly your social relationships with family, colleagues, and friends
Please provide information on whom you can depend on socially and emotionally
Professional/Academic Status
Are you Currently Working and/or Studying?
Please describe your situation academically and/or professionally
Interests
Please indicate/describe what activities interests you
Should be Empty:

Select theme:

Clinical Assessment Form

Spouse's Information

Personal Information

Health Assessment

Family Information and Social Relationships

Professional/Academic Status

Interests