Self-Assessment Questionnaire PERSONAL INFORMATIONFirst Name*Last Name*Phone*May I call / leave a message?*YesNoName of parent/guardian (if under 18 years old) First Last Referred byYour Age*Date of Birth* Date Format: MM slash DD slash YYYY Marital Status*Number of Children*Address* Street Address City State / Province / Region ZIP / Postal Code Email* May I email you?*YesNoPerson to contact in an emergency* First Last Contact number*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?*YesNoPsychiatrist’s / Psychotherapist’s name: First Last OCCUPATION INFORMATIONAre you currently employed?*YesNoWhat is your current position?Please list any employment related stressors:FAMILY HISTORYHas any family member experienced any psychiatric problems?*YesNoIf yes, please detail:HEALTH INFORMATIONAre you experiencing any health concerns?*How would you rate your health?*ExcellentGoodSatisfactoryUnsatisfactoryDo you have sleep problems? (Describe)Do you exercise?*YesNoIf yes, how many times a week?Do have appetite difficulties or eating habit problems?*YesNoWhat type of issue?Eating lessEating moreBingingRestrictingDo you drink alcohol?*YesNoIf yes, how many drinks a week:Do you use recreational drugs?*YesNoIf yes, what type and how often:In the past year have you experienced any significant life stresses?*YesNoIf yes, please explain:Please list your sources of emotional support:*Please check the following symptoms if you have experienced them:Depressed mood*In the last seven daysIn the pastNoAnxiety*In the last seven daysIn the pastNoPanic Attacks*In the last seven daysIn the pastNoMood swings*In the last seven daysIn the pastNoPhobias*In the last seven daysIn the pastNoObsessive thoughts*In the last seven daysIn the pastNoRepetitive behaviors*In the last seven daysIn the pastNoIntrusive thoughts re: trauma*In the last seven daysIn the pastNoFlashbacks re: trauma*In the last seven daysIn the pastNoEating disorder*In the last seven daysIn the pastNoBody image problems*In the last seven daysIn the pastNoAlcohol and/or substance abuse*In the last seven daysIn the pastNoRelationship difficulties*In the last seven daysIn the pastNoLearning disabilities*In the last seven daysIn the pastNoSuicidal thoughts*In the last seven daysIn the pastNoSuicide attempt*In the last seven daysIn the pastNoWhat are your goals for therapy?Anything else you think I should know?