ASSESSMENT
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Biological Sex
Male
Female
Other
Gender Identity
transgender male
transgender female
non-binary
agender
Other
Maritial Status
married
domestic partnership
divorced
single
Other
Previous Marriages
Ethnicity
Unknown
Multi-racial
White/Caucasian
Hispanic/Latino
Black/African American
Asian Pacific Islander
East Indian
Other
Languages Spoken
Adjustment Symptoms
Distress about a stressor that is out of proportion
Other
Anxious Symptoms
Restless
Fatigued
Difficulty Concentrating
Muscle Tension
Sleep Disturbance
Other
Depressive Symptoms
Depressed Mood/Diminished Interest or Pleasure in Activities
Weight Loss/Weight Gain
Insomnia/Hypersomnia
Psychomotor Agitation/Retardation
Fatigue/Loss of Energy
Diminished Concentration/Indecisiveness
Thoughts of Death/Suicidal Ideation/with plan/without plan/attempt
Other
Dissociative Symptoms
Depersonalization-outside observation of self
Derealization
Autobiographical Memory Loss
Other
Manic Symptoms
Inflated Self Esteem
Decreased Need for Sleep
Pressured Talking
Thoughts Racing/Flight of Ideas
Distractibility
Goal Directed Activity/Psychomotor Agitation
Engaging in Activities w/painful consequences
Other
Obsessive Symptoms
Obsessive Thoughts, Urges or Images
Compulsive Thoughts or Actions
Hoarding
Hair Pulling
Skin Picking
Preoccupation with perceived physical defects or flaws
Other
Trauma Symptoms (A1)
Exposure to Traumatic Event(s)
Other
Trauma Symptoms (B1)
Distressing Memories
Distressing Dreams
Dissociative Reactions
Psychological Distress at Cues Internal/External
Physiological Distress at Cues Internal/External
Other
Trauma Symptoms (C1)
Avoidance of Distressing Memories/Thoughts/Feelings
Avoidance of Distressing Reminders
Other
Trauma Symptoms (D2)
Inability to Remember Important Aspects of the Trauma
Exaggerated Negative Beliefs or Expectations
Distorted Cognitions about the Cause or Consequences of the Trauma
Persistent Negative Emotional State
Diminished Interest or Participation in Activities
Feelings of Detachment or Estrangement from Others
Persistent Inability to Experience Positive Emotions
Other
Trauma Symptoms (E-2)
Irritable Behavior and Angry Outbursts
Reckless/Self Destructive Behavior
Hypervigilance
Exaggerated Startle Response
Problems w/Concentration
Sleep Disturbance
Other
General Symptoms and Problems
Abandonment Issues
Adult Child of Alcoholic
Addictive Behavior
Aggressive Physical Behavior
Aggressive Verbal Behavior
Alcohol Use
Amnesia
Anger Issues
Anhedonia-inability to feel pleasure
Anorexia
Anxiety
Apathy
Auditory hallucinations
Binge Eating
Bulimia
Chronic Pain
Compulsive Gambling
Compulsive Sexual Behavior
Cutting-self mutilation
Decreased Appetite
Delusions
Depressed Mood
Derealization-surroundings appear unreal
Diet Pill Use
Difficulty w/Understanding
Dissociation-Disconnected w/Surroundings
Distorted Body Image
Distortion or Loss of Subjective Time
Distractibility
Dysregulation of Menstrual Cycle
Employment Problems
Encopresis-resisting bowel movements/leakage)
Enuresis (bedwetting)
Exaggerated Startle Response
Excessive Exercise
Excessive Internet Use
Excessive Sleep
Exposure to Traumatic Event
Family of Origin Concerns
Fatigue Tiredness
Fear
Fear of Open Spaces
Feelings of Guilt Shame
Feelings of Helplessness
Feelings of Loneliness
Feelings of Worthlessness
Financial Problems
Forgetfulness
Gender Identity Issues
Grief & Loss Issues
Histrionic-melodramatic
Homicidal Thoughts
Hyperactivity
Hypervigilence
Hypomania
Illegal Drug Use
Impulsive Spending
Increased Appetite
Indecisiveness
Insomnia
Intense Fear of Weight Gain
Intentional Food Restriction
Irritability
Laxative Abuse
Legal Problems
Low Energy
Low Motivation
Low Self Esteem
Malingering
Mania
Marital/Intimate Relationship Issues
Medical Issues
Medical Problems
Mood Swings
Occupational Problems
Over Counter Drug Abuse
Overwhelmed
Panic Attacks
Paranoia
Parent/Child Problems
Peer Relationship Problems
Perfectionism
Phobia
Poor Self Image
Postpartum Depression
Prescription Drug Abuse
Provocative/Seductive Behavior
Psychomotor Agitation
Psychomotor Retardation
Racing Thoughts
Recent Significant Weight Gain
Recent Significant Weight Loss
Recurrent Distressing Dreams
Recurrent Thoughts of Death
Refusal to Maintain Normal Body Weight
Restlessness
Seasonal Affective Disorder
Sad Mood
School Problems
Self Induced Vomiting
Self-Neglect/Poor Hygiene
Sense of Entitlement
Sexual Problems
Sibling Conflict
Social Isolation
Stress
Suicidal Thoughts
Tearfulness
Thought Blocking-thought/speech cessation
Time Management
Visual Hallucinations
Worry
Other
Areas of Life Affected
problems with primary support group
problems related to the social environment
occupational problems
economic problems
educational problem
problems related to interaction with the legal system
problems with access to health care services
housing problems
guardianship/competency problems
Other
Areas of Personal Functioning Affected
marriage/intimate relationships
family interactions/involvement
social interactions/involvement
school
self care
work
involvement in daily living
recreational/leisure/fitness activities
household
physical health
Severity
mild
moderate
severe
Other
Current Relationship with Alcohol
do not drink
moderate drinker
mild drinker
heavy drinker
excessive drinker
Other
Current Relationship with Illegal Drugs and/Non-Prescribed Prescription Medications
no use
mild use
moderate use
heavy use
excessive use
Other
Problematic History with Alcohol or Substance use:
no
alcohol use
illegal drug use
prescription drug misuse
Other
Current Self Harming Behaviors
no
yes
Other
Current Suicidal Behaviors with or without a Plan
no
without a plan
with a plan
attempt(s)
Other
Current Violent Behaviors with or without a Plan
no
without a plan
with a plan
acting out behaviors
Other
History of Self Harm, Suicidal or Violent Behaviors
no
self harm
suicidal behaviors
suicidal attempts
violent behaviors
Mental Status-Appearance
not assessed
poorly groomed
strange/bizarre
unusual
well groomed
casual and clean
informal
Mental Status-Behavior
not assessed
poor eye contact
relaxed
tearful
threatening
tics
appropriate
agitated
compulsive
fidgeting
hyperactive
impulsive
laughing
lethargic
Mental Status-Mood
not assessed
hypomanic/manic
normal (bright)
angry
anxious
depressed
euphoric
fearful
numb
sad
Mental Status-Orientation
not assessed
fully oriented to person, place, date, and time
completely disoriented
orriented to only person
oriented to only person and place
oriented to only place
oriented to only time
Current and Historical Relationship with Nuclear Family
Mental Status-Attitude
not assessed
cooperative
denial /maximizing
denial/minimizing
denial/rationalizing
evasive/guarded
threatening
uncooperative
withdrawn
Mental Status-Affect
not assessed
appropriate
constricted
expansive
flat
labile
tense
Mental Status-Thought
not assessed
logical
bizarre
coherent
delusions
eccentric
flight of ideas
Mental Status-Speech
not assessed
normal
fast
loud
monotone
pressured
slurred
soft
Mental Status-Intellectual Status
not assessed
no gross impairment noted
above average
average
below average
borderline
deficient
Mental Status-Judgement
not assessed
no gross impairment noted
good
fair
poor
immature
Mental Status-Insight
not assessed
no gross impairment noted
good
fair
poor
immature
Mental Status-Short Term Memory
not assessed
no gross impairment noted
intact
mildly impaired
moderately impaired
severely impaired
Mental Status-Long Term Memory
not assessed
no gross impairment noted
intact
mildly impaired
moderately impaired
severely impaired
Mental Status-Fund of Knowledge
not assessed
no gross impairment noted
accurate
mostly accurate
inaccurate
moderately limited
severely limited
Other
Past Counseling
no
yes
Other
Highest Education
grade school
high school
BA
MA
PhD
Employment Status
part time
full time
self-employed
disability
retired
unemployed
Other
Employer
Should be Empty: