Initial Client Assessment for Adults/Adolescents/Children

Patient First Name

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Patient Last Name

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Presenting Information and Current Symptoms:

What are the main reasons you are seeking psychiatric treatment?

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When did the problem(s) first begin?

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Please list your current symptoms that you feel are problematic or inhibit you from living your daily life.

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Please indicate if any of the following medical and psychiatric symptoms are present (P), or not present (NP):

Convulsions/Seizures

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Vision Problems

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Nausea/Vomiting

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Constipation/Urinary problems

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Arthritis

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Hallucinations

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Social Discomfort

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Poor Memory/Confusion

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Panic Attacks

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Addiction

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Allergies

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Chronic Pain

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Dizziness/Fainting

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Thyroid Problems

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Sexually Transmitted Disease

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Asthma

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Hearing Problems

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Diabetes

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Headaches

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Sadness/Moodiness

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Anxiety

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Hyperactivity

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Inattentiveness

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Obsessive/Compulsive Behavior

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Irritability/Anger

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Homicidal/Suicidal Thoughts

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Sleep Problems

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Paranoia

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Mood Swings

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Does the patient have any allergies?

Food

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Drug:

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Seasonal/Environmental Allergies:

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Other Allergy (please explain):

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Personal Medical/Surgical History:

Do you have any current or past medical conditions? Please explain:

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Please list any surgeries the patient has had in their lifetime, and indicate dates if possible.

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Have you experienced any traumatic injuries/accidents? If yes, please explain and include dates if possible.

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Please indicate if the patient has taken any of the following psychoactive medications or is currently being prescribed them by another practice. In the blank box next to the medications, please indicate an “H” for Helpful, and “NH” for not helpful, for each medication the patient has previously tried. If the medication has not been tried by the patient, please leave the box blank.

Mood Stabilizers

Geodon

Currently Taking (C) Or Past Medication (P)

Please select an option.

Helpful (H) or Not Helpful (NH)

Please select an option.

Medication Dose

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Side Effects Experienced or None

Please select an option.

Abilify

Currently Taking (C) Or Past Medication (P)

Please select an option.

Helpful (H) or Not Helpful (NH)

Please select an option.

Medication Dose

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Side Effects Experienced or None

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Depakote

Currently Taking (C) Or Past Medication (P)

Please select an option.

Helpful (H) or Not Helpful (NH)

Please select an option.

Medication Dose

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Side Effects Experienced or None

Please select an option.

Risperdal

Currently Taking (C) Or Past Medication (P)

Please select an option.

Helpful (H) or Not Helpful (NH)

Please select an option.

Medication Dose

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Side Effects Experienced or None

Please select an option.

Seroquel

Currently Taking (C) Or Past Medication (P)

Please select an option.

Helpful (H) or Not Helpful (NH)

Please select an option.

Medication Dose

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Side Effects Experienced or None

Please select an option.

Lithium

Currently Taking (C) Or Past Medication (P)

Please select an option.

Helpful (H) or Not Helpful (NH)

Please select an option.

Medication Dose

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Side Effects Experienced or None

Please select an option.

Tegretol

Currently Taking (C) Or Past Medication (P)

Please select an option.

Helpful (H) or Not Helpful (NH)

Please select an option.

Medication Dose

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Side Effects Experienced or None

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Haldol

Currently Taking (C) Or Past Medication (P)

Please select an option.

Helpful (H) or Not Helpful (NH) Please circle

Please select an option.

Medication Dose

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Side Effects Experienced or None

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Anti-Depressants

Trazodone

Currently Taking (C) Or Past Medication (P)

Please select an option.

Helpful (H) or Not Helpful (NH)

Please select an option.

Medication Dose

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Side Effects Experienced or None

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Zoloft

Currently Taking (C) Or Past Medication (P)

Please select an option.

Helpful (H) or Not Helpful (NH)

Please select an option.

Medication Dose

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Side Effects Experienced or None

Please select an option.

Prozac

Currently Taking (C) Or Past Medication (P)

Please select an option.

Helpful (H) or Not Helpful (NH)

Please select an option.

Medication Dose

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Side Effects Experienced or None

Please select an option.

Cymbalta

Currently Taking (C) Or Past Medication (P)

Please select an option.

Helpful (H) or Not Helpful (NH)

Please select an option.

Medication Dose

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Side Effects Experienced or None

Please select an option.

Celexa

Currently Taking (C) Or Past Medication (P)

Please select an option.

Helpful (H) or Not Helpful (NH)

Please select an option.

Medication Dose

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Side Effects Experienced or None

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Lexapro

Currently Taking (C) Or Past Medication (P)

Please select an option.

Helpful (H) or Not Helpful (NH)

Please select an option.

Medication Dose

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Side Effects Experienced or None

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Stimulants

Ritalin

Currently Taking (C) Or Past Medication (P)

Please select an option.

Helpful (H) or Not Helpful (NH)

Please select an option.

Medication Dose

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Side Effects Experienced or None

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Adderall

Currently Taking (C) Or Past Medication (P)

Please select an option.

Helpful (H) or Not Helpful (NH)

Please select an option.

Medication Dose

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Side Effects Experienced or None

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Concerta

Currently Taking (C) Or Past Medication (P)

Please select an option.

Helpful (H) or Not Helpful (NH)

Please select an option.

Medication Dose

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Side Effects Experienced or None

Please select an option.

Vyvanse

Currently Taking (C) Or Past Medication (P)

Please select an option.

Helpful (H) or Not Helpful (NH)

Please select an option.

Medication Dose

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Side Effects Experienced or None

Please select an option.

Straterra

Currently Taking (C) Or Past Medication (P)

Please select an option.

Helpful (H) or Not Helpful (NH)

Please select an option.

Medication Dose

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Side Effects Experienced or None

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Other Psychiatric Medications

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Please list all non-psychiatric medications currently taken by the patient:

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Does the patient have a family history of any medical conditions? Please explain.

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Family Psychiatric History:

Are the following members of your family currently or have previously been treated for any psychiatric conditions?

Mother

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Father

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Siblings

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Is there a family history of suicide or attempted suicide?

Please select an option.

If yes, please explain:

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Are you experiencing conflict within your family?

Please select an option.

If yes, please explain:

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Patient Psychiatric History:

Are you currently participating in any psychiatric care at another facility?

Please select an option.

If yes, where and what service?

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Do you have a previous history of psychiatric care that you are no longer participating in?

Please select an option.

If yes, please explain:

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Please list any previous Psychiatrists, Psychologists, or Therapists that the patient has seen:

Name or Facility

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Dates Seen (mm/yy-mm/yy)

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Medications Prescribed

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Hospitalized?

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Location

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Name or Facility

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Dates Seen (mm/yy-mm/yy)

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Medications Prescribed

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Hospitalized?

Please select an option.

Location

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Name or Facility

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Dates Seen (mm/yy-mm/yy)

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Medications Prescribed

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Hospitalized?

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Location

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Social History:

Please detail the Patient’s circumstances for the following:

Gender Identity:

Please select an option.

Other

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Sexual Orientation

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Other

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Marital History:

Please select an option.

Children:

Please select an option.

Living Situation: :

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Support System (Family, friends, etc.):

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Military History:

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If yes, what branch?

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If no, please explain:

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Are you financially secure (do you have food, shelter, water, clothes, ect)?

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Are you employed?

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Other

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If employed, what do you do for a living?

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Do you have any current legal charges?

Please select an option.

If yes, are you:

Currently on Probation?

Please select an option.

Court ordered for Psychiatric Treatment?

Please select an option.

Have an upcoming hearing?

Please select an option.

Registered on Megan’s Law?

Please select an option.

Education (Level achieved/performance)

Please select an option.

If the patient is enrolled in elementary school, middle school, or highschool, please answer the following
questions. If the patient is not enrolled in any of the above, please skip this section and move on to
“History of Abuse and Traumatic Events”.

Marital status of parents:

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If parents are separated/divorced, how old was child at time of separation?

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With whom does the child live?

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Custody

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List all people living in household

Name

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Age

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Relationship to child

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Name

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Age

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Relationship to child

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Name

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Age

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Relationship to child

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Name

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Age

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Relationship to child

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Place a check any behavior or problem that your child currently exhibits.

Has difficulty with speech

Has frequent tantrums

Has difficulty with hearing

Has frequent nightmares

Has difficulty with language

Has trouble sleeping (describe)

Has difficulty with vision

Has blank staring spells

Has difficulty with coordination

Rocks back and forth

Prefers to be alone

Bangs head

Does not get along well with other children

Is aggressive

Is shy or timid

Eats poorly

Is stubborn

Has poor bowel control (soils self)

Is much too active

Is more interested in things (objects) than in people

Engages in behavior that could be dangerous to self

Describe

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How do you describe the child’s friendships:

Please select an option.

School:

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Grade:

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Place a check to any educational problem that your child currently exhibits:

Has difficulty with reading

Has difficulty with arithmetic list

Has difficulty with spelling

Has difficulty with writing

Does not like school

Is your child in a special education class?

Please select an option.

If yes, please explain:

Please complete this field.

Has your child been held back in a grade?

Please select an option.

If yes, please explain:

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Has your child ever received special tutoring or therapy in school?

Please select an option.

If yes, please explain:

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Has your child ever been suspended or expelled?

Please select an option.

If yes, please explain:

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History of Abuse and Traumatic events (Please Select Y or N):

Physical Abuse:

Please select an option.

Emotional Abuse:

Please select an option.

Sexual Abuse:

Please select an option.

Domestic Violence:

Please select an option.

Witnessed Domestic Violence:

Please select an option.

Witnessed a traumatic event:

Please select an option.

Neglect:

Please select an option.

Experienced a death of a loved one:

Please select an option.

If yes to any of the above, is the abuse

Please select an option.

Do you feel safe in your current living situation?

Please select an option.

If you answered no, please explain:

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If you answered “yes” to any of the above abuse questions, please answer the following questions.

Have you had any unwanted memories of the traumatic event while you were awake?

Please select an option.

Have you experienced any unpleasant dreams about the traumatic event?

Please select an option.

Have there been times when you suddenly acted or felt as if the traumatic even were actually happening again?

Please select an option.

Have you gotten emotionally upset when something reminded you of the event?

Please select an option.

Have you blamed yourself for the traumatic even or what happened as a result of it?

Please select an option.

Have you had any strong negative feelings, such as fear, horror, anger, guilt, or shame?

Please select an option.

Have you been less interested in activities that you used to enjoy?

Please select an option.

Have you been especially alert of watchful, even when there was no specific threat or danger?

Please select an option.

Have you had any strong startle reactions?

Please select an option.

Have you had any problems with concentration?

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Have you had any problems falling asleep?

Please select an option.

Have you experienced a recent loss?

Please select an option.

If yes, please briefly explain the loss:

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If there anything else that you feel I should know regarding your trauma history:

Please select an option.

If yes, please explain:

Please complete this field.

History of Substance Abuse:

Has the patient previously or is the patient currently abusing any of the following substances? Please note, this information is protected and will not be shared without written consent from the patient.

Substance Type Alcohol

Alcohol

Please select an option.

Current Use (Last 6 Months)

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Frequency/Amount

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Past Use

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Frequency/Amount

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Substance Type Tobacco

Tobacco

Please select an option.

Current Use (Last 6 Months)

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Frequency/Amount

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Past Use

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Frequency/Amount

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Substance Type Tobacco

Marijuana

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Current Use (Last 6 Months)

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Frequency/Amount

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Past Use

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Frequency/Amount

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Substance Type K2/Spice

K2/Spice

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Current Use (Last 6 Months)

Please select an option.

Frequency/Amount

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Past Use

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Frequency/Amount

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Substance Type Cocaine/Crack

Cocaine/Crack

Please select an option.

Current Use (Last 6 Months)

Please select an option.

Frequency/Amount

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Past Use

Please select an option.

Frequency/Amount

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Substance Type Ecstasy

Ecstasy

Please select an option.

Current Use (Last 6 Months)

Please select an option.

Frequency/Amount

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Past Use

Please select an option.

Frequency/Amount

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Substance Type Methamphetamines

Methamphetamines

Please select an option.

Current Use (Last 6 Months)

Please select an option.

Frequency/Amount

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Past Use

Please select an option.

Frequency/Amount

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Substance Type Pain Medication/Rx Meds

Pain Medication/Rx Meds

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Current Use (Last 6 Months)

Please select an option.

Frequency/Amount

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Past Use

Please select an option.

Frequency/Amount

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Substance Type Inhalants

Inhalants

Please select an option.

Current Use (Last 6 Months)

Please select an option.

Frequency/Amount

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Past Use

Please select an option.

Frequency/Amount

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Substance Type Heroin

Heroin

Please select an option.

Current Use (Last 6 Months)

Please select an option.

Frequency/Amount

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Past Use

Please select an option.

Frequency/Amount

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Substance Type Xanax/Valium/Klonopin

Xanax

Please select an option.

Current Use (Last 6 Months)

Please select an option.

Frequency/Amount

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Past Use

Please select an option.

Frequency/Amount

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Substance Type PCP/LSD

PCP/LSD

Please select an option.

Current Use (Last 6 Months)

Please select an option.

Frequency/Amount

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Past Use

Please select an option.

Frequency/Amount

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Substance Type Steroids

Steroids

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Current Use (Last 6 Months)

Please select an option.

Frequency/Amount

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Past Use

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Frequency/Amount

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Substance Type Tranquilizers

Tranquilizers

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Current Use (Last 6 Months)

Please select an option.

Frequency/Amount

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Past Use

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Frequency/Amount

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Other

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Current Use (Last 6 Months)

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Frequency/Amount

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Past Use

Please select an option.

Frequency/Amount

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Do you use tobacco?

Please select an option.

If yes, what do you use and how often

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Do you have a history of overdose?

Please select an option.

If yes, when and with what substance:

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Do you have a history of withdrawal symptoms?

Please select an option.

If yes, what substance and what symptoms:

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Do you have a history of withdrawal seizures?

Please select an option.

If yes, when:

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Do you have a history of sharing needles?

Please select an option.

Have you ever been to an inpatient detox unit?

Please select an option.

If yes, where and when:

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Does anyone important to you believe you a problem with substances?

Please select an option.

(If yes, please briefly explain:

Please complete this field.

Have you ever participated in outpatient drug and alcohol tx?

Please select an option.

If yes, where and when:

Please complete this field.

Have you ever been to an inpatient rehab?

Please select an option.

If yes, where and when:

Please complete this field.

Developmental History:

Has the patient ever been diagnosed with a learning disability?

Please select an option.

If yes, please explain:

Please complete this field.

Does the patient have problems reading and/or writing?

Please select an option.

If yes, please explain:

Please complete this field.

Are the patient’s motor skills inhibited in any way?

Please select an option.

If yes, please explain:

Please complete this field.

Did the patient reach all developmental milestones at age appropriate at appropriate times:

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Is there anything else that you feel I should know about you before engaging in treatment?

Please select an option.

If yes, please explain:

Please complete this field.

The patient/authorized parent or guardian authorizes that the information provided in this document is true to the best of my knowledge, but also retain the ability to modify my response at any time. The clinician understands that this information may change at any time.

PRINTED name of Patient or Authorized Parent/Guardian

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Date

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SIGNATURE of Patient or Authorized Parent/Guardian

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Date

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SIGNATURE of Clinician

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Date

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