Mental Health Rehabilitation Assessment
Please complete this assessment to help us understand your current mental health status and rehabilitation needs.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Current Living Situation
*
Living alone
With family
Supported housing
Other
Primary Reason for Assessment
*
Mental Health Diagnosis (if any)
Current Symptoms Severity
*
None
1
2
3
4
5
6
7
8
9
Severe
10
1 is None, 10 is Severe
Functional Abilities Assessment
*
Rows
Independent
Needs Some Assistance
Requires Full Assistance
Self-care (hygiene, dressing)
1
2
3
Managing medication
4
5
6
Daily living skills (cooking, cleaning)
7
8
9
Social interactions
10
11
12
Managing finances
13
14
15
Support Systems Available
Family
Friends
Community services
Mental health professional
Other
Risk Factors (select all that apply)
Substance use
Recent hospitalization
History of self-harm
No risk factors
Other
Personal Rehabilitation Goals
Overall Satisfaction with Current Mental Health Services
1
2
3
4
5
Submit Assessment
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