Clinical Assessment Form
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Date of Birth
-
Month
-
Day
Year
Date
Age
Status
Single
Married
Divorced
Separated
Widowed
Spouse's Information
Name of Spouse
First Name
Last Name
Phone Number
Please enter a valid phone number.
Alternative Phone Number (if any)
Please enter a valid phone number.
Personal Information
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Name of Referrer
Prefix
First Name
Last Name
Health Assessment
Chief Concern
Please indicate how long you have been having the condition
Do you currently have any other known medical problems?
Yes
No
Please explain
Please indicate how long you have been having the condition
Have you ever been treated for any of the following?
Head injury
Strokes
Seizures
Fainting
Loss of consciousness
Neurologic conditions (Multiple sclerosis, Parkinson’s)
Cancer
Headaches
Diabetes
Kidney Disease
Allergies
Chronic Fatigue
High Fever
Surgeries
Other
Please explain
Have you previously seen a therapist or psychiatrist?
Yes
No
Please explain
Have you ever been hospitalized for medical or mental illness?
Yes
No
Please explain
Indicate when, where, and reason
Are you currently taking any prescription medications?
Yes
No
Please indicate the names and dosage
Have you previously taken any prescription medications?
Yes
No
Please indicate (names, dosage, when)
Do you drink alcohol or use recreational drugs?
Yes
No
Please indicate the kind and frequency
Name Of Your Primary Care Physician
Prefix
First Name
Last Name
Suffix
Name Of Psychiatrist/Psychologist (if applicable)
Prefix
First Name
Last Name
Suffix
Date of Last Complete Physical Examination
-
Month
-
Day
Year
Date
What type of food do you regularly eat?
How frequent do you exercise and how long?
Family Information and Social Relationships
Family Relations
Father
Mother
Age (if deceased, please indicate age, date of death, and cause of death)
Country of Origin
Describe your relationship
Were you adopted?
Yes
No
Number of Years Your Parents Married
Are They Divorced?
Yes
No
How Old Were You When They Divorced?
Have had family difficulties during growing up?
Please describe
Siblings
Children
Struggles During Childhood:
Yes
No
Age
Brief Description
Learning Difficulty
1
2
Hyperactivity
3
4
Fears in School
5
6
Experienced Being Bullied
7
8
Eating Disorders
9
10
Witnessing Violence at Home
11
12
Experienced Sexual, Physical or Emotional Abuse
13
14
Family Mental Health
Yes
No
Relationship
Anxiety Disorder
15
16
Bipolar or Mood Disorder
17
18
Depression
19
20
Domestic Violence
21
22
Eating Disorders
23
24
Excessive Alcoholism
25
26
Obsessive-Compulsive Behavior
27
28
Suicidal
29
30
Substance Abuse
31
32
Schizophrenia
33
34
Undergone Counseling or Psychotherapy
35
36
Are you living in with a partner?
Yes
No
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?
Yes
No
Please describe your situation academically and/or professionally
Interests
Please indicate/describe what activities interests you
Submit
Should be Empty: