Client Information
Full Name
Date of Birth
Gender
Date of Assessment
Referral Source
Social History
Marital Status
Do you have a spouse?
Do you have any children?
Who lives with you in your home?
Highest Grade, Diploma, or Degree Completed
Current Occupation
Presenting Concerns
Describe the symptoms for which you’re seeking help
When did you first experience the above symptoms?
How are these symptoms affecting your daily life?
What do you think may have caused the symptoms?
Have you ever seen a specialist to help with the above problem(s)?
For how long did you see the specialist(s)?
What were your specialist(s) conclusions and recommendations?
What are your treatment goals?
Additional Information
Do you feel depressed or blue?
Do you have little interest or pleasure in doing things?
Do you have any problems with sleeping?
Do you feel tired or have little energy?
Do you have poor appetite?
Do you overeat?
Do you feel bad about yourself?
Do you have trouble concentrating?
Are you forgetful?
Are you impulsive?
Are you easily irritable?
Do you have crying spells?
Do you worry all the time?
Do you have any anxiety attacks?
Do you have any hallucinations?
Are you moving or speaking slowly that others can notice?
Are you moving or speaking too quickly that others can notice?
Is it hard for you to stay still?
Have you ever had feelings or thoughts that you didn’t want to live?
Do you have a history of substance abuse or alcohol problems?
Have you ever been arrested?
Do you hear or see things that others can’t?
Have you attempted suicide in the past or do you ever have thoughts about not wanting to be here?
Have you engaged in self-harming behaviors?
Have you ever experienced problems with eating too much or too little?
Progress Notes
Appearance and Behavior
Speech and Language
Mood
Affect
Thought Process
Thought Content
Perceptions
Cognition
Insight
Judgment
Generate