Mental Health Assessment Form

Full Name*

First NameLast Name

Date of Birth*

Date

Gender*

MaleFemale

Phone Number*

Email*

example@example.com

Provider*

Member ID*

Group #*

Name*

First NameLast Name

Relationship*

Emergency Contact Phone Number*

What brings you here today? (Please describe briefly)*

Have you previously received mental health treatment? (Yes/No)*

YesNo

If yes, please provide details:

Any past diagnoses?

Please check any symptoms you are currently experiencing:*

Do you have any current medical conditions? (Yes/No)*

YesNo

If yes, please specify:

Are you taking any medications? (Yes/No)*

YesNo

If yes, please list:

Do you have a support network? (e.g., friends, family) (Yes/No)*

YesNo

If yes, please describe: *

What do you hope to achieve through therapy?*

Signature

Date Signed

Date

This form serves as a foundation for understanding the client's needs and tailoring the therapeutic approach accordingly.

Laura I. Davis-Perry, LSW, MSW, LISW-S, BSP, HB
Founder of Conquering Walls Counseling Agency, LLC
Phone - 614-357-0686

"Conquering walls caused by life's adversity one brick at a time!"
HIPAA (Health Insurance Portability and Accountability Act) sets standards for safeguarding protected health information (PHI). While there is no specific requirement for a HIPAA email disclaimer within the legislation itself, at CWCALLC, we include this disclaimer in our email communications to ensure compliance and protect sensitive information. This email and any attachments contain confidential and privileged information intended only for the identified recipient. Please do not share this information with unauthorized individuals, and don't hesitate to notify CWALLC if you received this information in error.

Client Information

Insurance

Emergency Contact

Presenting Concerns

Mental Health History

Current Symptoms

Medical History

Support System

Goals for Therapy