Self-Assessment Questionnaire PERSONAL INFORMATIONFirst 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* 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?* 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 INFORMATIONAre you currently employed?* Yes No What is your current position? Please list any employment related stressors:FAMILY HISTORYHas any family member experienced any psychiatric problems?* Yes No If yes, please detail:HEALTH INFORMATIONAre 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?
