Assessment Questionnaire – K·Rena Group

PERSONAL INFORMATION

First Name*

Last Name*

Phone*

May I call / leave a message?*

Yes
No

Name of parent/guardian (if under 18 years old)

First Last

Referred by

Your Age*

Date of Birth*

Marital Status*

Number of Children*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Email*

May I email you?*

Yes
No

Person 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?*

Yes
No

Psychiatrist’s / Psychotherapist’s name:

First Last

OCCUPATION INFORMATION

Are you currently employed?*

Yes
No

What is your current position?

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?*

Excellent‎
Good‎
Satisfactory‎
Unsatisfactory

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?*

Yes
No

What type of issue?

Eating less
Eating more
Binging
Restricting

Do you drink alcohol?*

Yes
No

If yes, how many drinks a week:

Do you use recreational drugs?*

Yes
No

If yes, what type and how often:

In the past year have you experienced any significant life stresses?*

Yes
No

If 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 days‎
In the past‎
No

Anxiety*

In the last seven days‎
In the past‎
No

Panic Attacks*

In the last seven days‎
In the past‎
No

Mood swings*

In the last seven days‎
In the past‎
No

Phobias*

In the last seven days‎
In the past‎
No

Obsessive thoughts*

In the last seven days‎
In the past‎
No

Repetitive behaviors*

In the last seven days‎
In the past‎
No

Intrusive thoughts re: trauma*

In the last seven days‎
In the past‎
No

Flashbacks re: trauma*

In the last seven days‎
In the past‎
No

Eating disorder*

In the last seven days‎
In the past‎
No

Body image problems*

In the last seven days‎
In the past‎
No

Alcohol and/or substance abuse*

In the last seven days‎
In the past‎
No

Relationship difficulties*

In the last seven days‎
In the past‎
No

Learning disabilities*

In the last seven days‎
In the past‎
No

Suicidal thoughts*

In the last seven days‎
In the past‎
No

Suicide attempt*

In the last seven days‎
In the past‎
No

What are your goals for therapy?

Anything else you think I should know?

Self-Assessment Questionnaire

PERSONAL INFORMATION

OCCUPATION INFORMATION

FAMILY HISTORY

HEALTH INFORMATION