Psychosexual Evaluation Intake Form
Please complete this form to provide important background information for your upcoming psychosexual evaluation. Your responses are confidential and will help guide your assessment.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Current Relationship Status
*
Single
Married/Partnered
Divorced
Widowed
Other
What is the primary reason for your referral or evaluation request?
*
Relevant Medical/Psychiatric History
*
Rows
Yes/No
Details (if Yes)
Current medical conditions
1
History of psychiatric treatment
2
Current medications
3
History of substance use
4
Have you previously participated in any psychological or psychosexual evaluations?
*
Yes
No
Please rate your current level of concern regarding the following areas:
*
Rows
Not at all concerned
Mildly concerned
Moderately concerned
Very concerned
Sexual behaviors
5
6
7
8
Sexual thoughts or urges
9
10
11
12
Relationship issues
13
14
15
16
Legal concerns related to sexual behavior
17
18
19
20
Have you experienced any of the following behaviors? (Check all that apply)
Difficulties with sexual impulse control
Concerns about sexual orientation or identity
History of sexual trauma or abuse
None of the above
Other
Is there anything else you would like the evaluator to know about your background, concerns, or goals for this assessment?
Submit Evaluation
Should be Empty: