Client Assessment
to be filled out prior to session & any questions may be emailed to mgedert9@gmail.com. The information on this form will be kept confidential, this form is not HIPAA compliant.
What is your presenting issue(s) for which you are seeking support?
When and under what circumstances do you think this issue began?
What specifically about your issue is leading you to seek help?
What other kinds of therapies have you tried? Please explain:
What life-style or mindset changes have been at least partially successful (if any?)
What other issues, either linked or not linked to the presenting issue do you need support with?
Medical History
Have you ever been diagnosed with a mental illness? If yes, please explain:
Have you been under regular medical or psychological treatment in the past year? If yes, please explain:
Have you ever been treated for an emotional/behavioral problem? If yes, please explain:
Have you ever had or do you have any prolonged illness: If yes, please explain:
Please list all of the current medications you are taking:
Please provide the name(s) and contact information of your current doctor(s) and/or therapist(s):
Have you had or are you experiencing:
Anxiety
Depression
Insomnia
Addiction
Self Harm
Suicidal Ideation
Chronic Illness
Other
If you checked any of the above, please explain further:
Do you drink alcohol?
no
occasionally
moderately
daily
Do you use marijuana/ marijuana products?
no
occasionally
moderately
daily
Are there other substances that you use on a regular, semi-regular or occasional basis? Please list substance and frequency.
How many hours of sleep do you get per day on average?
By signing this document, I am confirming that all information is true to the best of my knowledge.
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