Name:

ID No:
Counseling Initial Assessment
Date of Initial Assessment:

Contact Details
Today's Date
07-06-2023

First Name Last Name

Preferred Name

Street Address

City State

Postal Code Phone (Mobile)

Phone (Other) Email Address

Personal Information
Gender
Female Male
Social Security Number
Non-Binary Prefer Not to Answer

Referred by Birthdate

Race/Ethnicity
American Indian or Alaska Native Asian
Black or African American Hispanic or Latino
Native Hawaiian or Other Pacific Islander White
Two or More Races Prefer Not to Answer
Other:

Employment Status
Employed - Full-time Employed - Part-time
Self-employed Out of work
Stay-at-home parent Student
 Retired Unable to work

Relationship Status
Single Single living with partner
Married Divorced
Separated Widowed

Have you ever been in trouble with the law?

Yes No

If yes, please describe how (include any periods where you were detained/in jail)

Emergency Contact
Emergency Contact First Name Emergency Contact Last Name

Emergency Contact Phone (Mobile) Relationship to Emergency Contact

Financial Information
Financial Information
Insurance Self-pay cash Self-pay debit/credit card
Other:

Insurance company name

Policy number Group number

Current Issue
In your own words, describe the reason for your visit today

How long has this been a problem?

How often do you experience this issue?

What would you say is your most immediate need?

Are you in any immediate physical danger?

When did you first consult a professional about this? (counselor, physician, social worker, etc.)?

What do you hope to see as the outcome this evaluation/counseling/treatment?

Symptoms Assessment (Check the symptoms/issues you are experiencing)

Physical Pain
Amount of pain you feel
None Mild
Moderate Severe
Extreme

Source of Pain

Are You experiencing any of the following?

Loss of interest in activities Fatigue/loss of energy Thoughts of self-harm
Feeling of hopelessness Feeling of worthlessness Trouble concentrating
Recurrent dark thoughts about yourself Recurrent dark thoughts about others Feeling sad or depressed
Anxiety An unsettled feeling that won't go away Excessive energy
Hallucinations Impulse control issues Irritability
Unexplained anger or rage Libido changes Panic attacks
Paranoia Changes in sleep pattern Grief
None

Mental Health History

Do you have any history of emotional or mental trauma?
Yes No

If yes, please explain the details.

Have you ever seen a mental health professional or counselor about this issue?
Yes No

If yes, please list name(s) of professional.

If yes, please give approximate dates of counseling.

 Have you had a previous mental health diagnosis?
Yes No

If yes, what was that diagnosis?

If you have had this issue before, what types of activities/therapy helped you and why?

Do you or have you ever taken prescription medications for mental health concerns?
Yes No

If yes, please list the names of the medications, approximately when you started/stopped taking it, and whether it helped

Have you ever experienced any type of abuse? (physical, mental, financial, etc.)
Yes No Prefer Not to Answer

If yes, please describe

Substance Use/Addiction History

Check the box next to any substances you have used or still use.
Alcohol Tobacco Vaping
Marijuana/Cannabis Opioids Hallucinogens (LSD)
Heroin Methamphetamines Cocaine
Stimulants (Pills) Stimulants (Energy Drinks) Ecstasy
Methadone Tranquilizers Pain killers

For any you have used, please list the frequency and dates of use.

Have you ever been treated for drug or alcohol abuse?

Yes No

If yes, when and where?

Have you ever quit and then relapsed?

Yes No

Medical History
Are you currently being treated for a medical condition?
 Yes No

If yes, please describe.

List any prior illnesses, operations, and accidents.

Are you currently taking any prescription medications for medical-related issues?
Yes No

If yes, please list medication and frequency taken.

List the name of your primary care physician

Primary care physician contact details

List the names of any other physicians you see for medical issues.

Family History
Fill in your current household & family information.
Is yes, please describe below.

Is there any history of abuse in your family?

Age

Gender
Female Male
Non-Binary Prefer Not to Answer

Living with you?

Yes No

Relationship Status
Positive Weak/Uncertain Stressful
 Biological or non-biological?
Biological Non-biological

Is there a history of mental health issues in your family?

Yes No

Is yes, please describe below.

Is there any history of abuse in your family?

Education & Employment

Education
Employer Details
Company Name Company Phone Number

Manager First Name Manager Last Name

Manager Phone Number

Company Street Address

Company City

Company State Company Country

How long have you worked with this company (in years/months)?

Employer Details
Other
Please share any other details that you would like us to know.