CLIENT ASSESSMENT QUESTIONNAIRE There was an error trying to submit your form. Please try again. This information is confidential. Please leave blank any questions you do not wish to answer. Name This field is required. Name & Tel. of Parent/Guardian This field is required. Referred By Doctor Family Friend Online Other Date of Birth This field is required. Marital Status * Select an option Single Married Divorced Seperated Widowed Engaged Cohabiting Domestic Partnership Civil Union This field is required. Number of Children Address Home Phone This field is required. May I leave a Message? Select an option Yes No Work Phone This field is required. May I leave a Message? Select an option Yes No Cell Phone This field is required. May I leave a Message? Select an option Yes No Email This field is required. May I email you? Select an option Yes No Would you like to be added to my newsletter email list? Approx. 3-4 newsletters a year Select an option Yes No Person to contact in an emergency This field is required. Please list any medications you are currently taking Please list any psychiatric medications you have taken in the past Are you currently receiving psychiatric and/or psychotherapy services? Select an option Yes No Psychiatrist’s/ Psychotherapist’s Name This field is required. OCCUPATION INFORMATION Are you currently employed? Select an option Yes No What is your current position? This field is required. Please list any employment related stressors: FAMILY HISTORY Has any family member experienced any psychiatric problems? Yes No If yes, please detail HEALTH INFORMATION Are you experiencing any health concerns? How would you rate your health? Unsatisfactory Satisfactory Good Excellent Do you have sleep problems? (Describe) Do you exercise? Yes No If yes, how many times a week? Do have appetite difficulties or eating habit problems? Select an option Yes No Do you drink alcohol? Select an option Yes No If yes, how many units a week Do you use recreational drugs? Select an option Yes No If yes, what type and how often? Select an option Less Often Often Very Often In the past year have you experienced any significant life stresses? This field is required. Please list your sources of emotional support This field is required. Submit There was an error trying to submit your form. Please try again.
