Filer's Name:

Assessment

Client Name: Date:

DOB: Age: Gender:

Address:

City: State:

Zip:

Primary Telephone:

Referral information:

CONFIDENTIALITY AGREEMENT: Client information is confidential except for: Information which can be shared with the paying insurance or processor; information which suggests possible child abuse or endangerment; information which suggests that the client is a danger to self or others; information which indicates behavior which is a serious risk to a minor; information which may be required by a court order, or as prescribed by law; and information that client or guardian requests to be released.

I have read and understand the above.

Client Signature:_________________________________________________ Date:________

Signature of parent

or legal guardian:________________________________________________ Date:_______

Previous Conditions

Condition:	Since:	Receiving Treatment?:

When was your last physical?

Current Medications:

Medication:	Dosage:	How often?:	Reason:	Date Begun:	Doctor:
		time/s

Previous Psychiatric/Psychological/Counseling Treatment:

Date Started:	Ended:	Location:	Treatement Type:	Doctor/Clinician:	Reason:

What brought you in today? What led up to this? When did this start?

Support System/Social Behaviors:

Work/School Function:

Family Relationships:

Any problems with authority figures/other people:

Legal/Financial Issues:

Alcohol Use? No Yes

How much/how often?

Since when?

Drug Use? No Yes

Name	Frequency	Using Since?
	times

Suicidal Thoughts? No Yes

Do you have a plan? No Yes

Past Attempts? No Yes

Dates:

Homicidal Thoughts? No Yes

Irritable daily? No Yes

Decreased interests? No Yes

Appetite No Yes

Weight? No Yes

Sleep? No Yes

Concentration? No Yes

Energy? No Yes

Observed sluggishness? No Yes

Feel worthless? No Yes

Feel guilty? No Yes

Feel hopeless? No Yes

Crying spells? No Yes

Racing thoughts? No Yes

Rapid mood swings? No Yes

Anxiety? No Yes

Restriciting No Yes

Vomiting No Yes

Diuretics or laxatives No Yes

Exercising excessively No Yes

Over eating No Yes

Cutting/scratching/burning No Yes

Psychosis; delusions or hallucinations No Yes

Stealing No Yes

Being home/Curfew No Yes

House work/Chores No Yes

Getting Up No Yes

Arguing No Yes

Attending work/Cutting classes No Yes

Working/Doing homework No Yes

Other No Yes

When angry do you/are you:

Physically abusive: No Yes

Break things: No Yes

Verbally abusive: No
Yes

History of sexual/physical abuse: No Yes

DCFS involvement No Yes

Conflicts or problems related to sexuality or your sexual orientation? No Yes

Are you active in any religious denomination or faith? No Yes

Your Strengths:

Strength:

Your Weaknesses:

Weakness:

Family mental health and substance abuse history:

Relation:	Type:	Description:

Client’s thoughts on goals for treatment:

Clinician use only

DSM IV Codes Diagnoses

Axis I ______________ ________________________________________

______________ ________________________________________

Axis II ______________ ________________________________________

Axis III ______________________________________________________________

Axis IV Psychosocial stressors: (circle all that apply)

Problems with: Primary support group Economics

Social environment Access to healthcare services

Education Interaction with the legal system/crime

Occupation Other:__________________________

Housing

Axis V Current GAF: ________ GAF past 12 months: ________

Clinician’s signature:___________________________________________________

Date:______________________________