ASSESSMENT QUESTIONNAIRE

ASSESSMENT QUESTIONNAIRE

This information is confidential. Please leave blank any questions you do not wish to answer.
PERSONAL INFORMATION
Full Name

First NameLast Name
Telephone

Area CodePhone Number
May I call/ leave a message?
Name of parent/guardian (if under 18 years old):

First NameLast Name
Referred by:
Age:
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Marital Status:
Number of Children
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
May I email you?
May I add you to my newsletter list?
Person to contact in an emergency:

First NameLast Name
Contact Number:

Area CodePhone Number
Please list any medications you are currently taking:
Please list any psychiatric medications you have taken in the past:
Are you currently receiving psychiatric and/or psychotherapy services?
Psychiatrist’s/ Psychotherapist’s name:

First NameLast Name
OCCUPATION INFORMATION
Are you currently employed?
What is your current position?
Please list any employment related stressors:
FAMILY HISTORY
Has any family member experienced any psychiatric problems?
If yes, please detail:
HEALTH INFORMATION
Are you experiencing any health concerns?:
How would you rate your health? (please circle one)
Do you have sleep problems? (Describe)
Do you exercise?
If yes, how many times a week?
Do have appetite difficulties or eating habit problems?
(Circle where applicable):
Do you drink alcohol?
If yes, how many units a week:
Do you use recreational drugs?
If yes, what type and how often:
In the past year have you experienced any significant life stresses?
If yes, please explain:
Please list your sources of emotional support:
Please check the following symptoms if you have experienced them:
Depressed mood
Anxiety
Panic Attacks
Mood swings
Phobias
Obsessive thoughts
Repetitive behaviors
Intrusive thoughts re: trauma
Flashbacks re: trauma
Eating disorder
Body image problems
Alcohol and/ or substance abuse
Relationship difficulties
Learning disabilities
Suicidal thoughts
Suicide attempt
What are your goals for therapy?
Anything else you think I should know?
Please verify that you are human
Should be Empty:

PERSONAL INFORMATION

OCCUPATION INFORMATION

FAMILY HISTORY

HEALTH INFORMATION