Clinical Personality Assessment Form
Complete this form to share background information and respond to personality assessment items for review.
Assessment Profile
Respondent Name
*
First Name
Last Name
Age
Role or Context
*
Student
Employee
Manager
Parent
Caregiver
Self-employed
Retired
Other
Reason for Assessment
*
Personality Assessment Items
Mood stability
*
Very unstable
1
2
3
4
Very stable
5
1 is Very unstable, 5 is Very stable
Social interaction style
*
Reserved
Balanced
Outgoing
Variable
Other
Personality pattern rating
Rows
Never
Rarely
Sometimes
Often
Almost always
Stress response is easily overwhelmed
1
2
3
4
5
Impulsive decisions occur without much forethought
6
7
8
9
10
Self-image is generally stable
11
12
13
14
15
Relationships are maintained consistently
16
17
18
19
20
Common stress responses
Withdraws
Becomes irritable
Overthinks
Seeks reassurance
Acts impulsively
Remains calm
Other
Interpretation and Follow-up
Main concerns or goals for this assessment
*
Preferred follow-up method
Phone
Email
Secure message
No preference
Other
Submit
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