Initial Assessment and Treatment Plan
Please complete this form to help us understand your needs and develop an effective treatment plan.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Information (Email Address)
*
example@example.com
Contact Information (Phone Number)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Presenting Concerns (Please describe the main issues or symptoms you are experiencing)
*
Duration of Presenting Concern(s)
*
Please Select
Less than 1 week
1-4 weeks
1-6 months
More than 6 months
Other
Relevant History (medical, psychological, social, or family history)
Symptom Assessment
*
Rows
Not at all
Mild
Moderate
Severe
Anxiety
1
2
3
4
Depression
5
6
7
8
Sleep problems
9
10
11
12
Appetite changes
13
14
15
16
Mood swings
17
18
19
20
Concentration difficulties
21
22
23
24
Are there any current risk factors or safety concerns?
*
Suicidal thoughts
Self-harm
Harm to others
None
Other
How are your current symptoms impacting your daily functioning?
*
No impact
Mild impact
Moderate impact
Severe impact
What are your main goals for treatment?
*
Preliminary Treatment Plan / Recommendations
Submit Assessment
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