New Patient Assessment

Dear Client,

The following information will help the clinic staff obtain an understanding of you and/or your spouse/significant other (SO) as quickly as possible. Please complete it to the best of your ability, and do not worry if you are unable to answer some the questions.

Thank you very much.

Family members

In-Home Name Age Relationship Highest Grade Remove


Major Problems/Concerns *

Problem Checklist

Check all that apply.

Past Psychiatric History

Psychiatric Medications

Medication Dose Date

Suicide Attempts

Circumstances When Remove

Psychiatric Hospitalizations

Circumstances When Remove

Medical History

Medical Hospitalizations

Circumstances Treatment/Outcome When Remove

Developmental and Perinatal History

Child(ren) Condition at Birth

Overall Health Pounds Ounces Remove

First Year of Life

Academic History

Leisure Activities

Family History

Please indicate the presence in biological relatives of any psychiatric problem, such as depression, suicide, alcoholism, drug abuse, anxiety panic attacks, manic-depressive (bipolar) illness, schizophrenia, mental retardation, autism, learning disability, hyperactivity, attention deficit disorder, childhood behavior problems, school or academic problems, narcolepsy, legal problems, brain trauma.

Family Circumstances

Current Functioning