New Client Pre-Assessment

New Client Pre-Assessment

"Step by Step to Recovery"
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail
example@example.com
How did you hear about us?*
Please Specify*
In your own words, describe the current problems as you see them:
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?

YesNo
When were you last seen.

MonthDayYear
Date
If yes, please list counselor name and number. When was your last treatment. First Name Last Name Area Code Phone Number
Symptoms: Please check any symptoms or experiences that you have had in the past three months or 60 days.

Difficulty sleepingChanges in eating/appetiteDo you have a lost of interest in previously enjoyed activitiesDo you find yourself spending an increase time aloneAre you experiencing panic attacksDo you avoid certain people or places for unexplained or unclear reasonsOutburst of Anger that happens frequently or without you knowing.Difficulty in concentration or thinkingDifficulty in solving your own problemsFeeling stressed out due to recent or past eventsDo you feel like harming yourself or others
Thank you for completing your Pre-Assessment Form. A staff member of The T.R.A.U.M.A. Center will contact you shortly to schedule your initial assessment and connect you with a counselor who can assist you on your healing journey.
The T.R.A.U.M.A. Center

5618B White Bluff Road

Savannah, GA 31405

912-438-6803
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