COUNSELING ASSESSMENT FORM
Assessment Date
/
Month
/
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Client Name
Client D.O.B.
*
-
Month
-
Day
Year
Date
Counselor's Name
Counselor's Email
example@example.com
PRESENTING PROBLEM:
CURRENT SYMPTONS CHECKLISTCURRENT SYMPTONS CHECKLIST
Rows
Client's Response
Depressed mood
Yes
No
Appetite disturbance
Yes
No
Sleep disturbance
Yes
No
Elimination disturbance
Yes
No
Fatigue/low energy
Yes
No
Psychomotor retardation
Yes
No
Poor concentration
Yes
No
Poor grooming
Yes
No
Mood swings
Yes
No
Agitation
Yes
No
Emotionality
Yes
No
Irritability
Yes
No
Generalized anxiety
Yes
No
Panic attacks
Yes
No
Phobias
Yes
No
Obsessions/compulsions
Yes
No
Bingeing purging
Yes
No
Laxative/diuretic abuse
Yes
No
Anorexia
Yes
No
Paranoid ideation
Yes
No
Circumstantial symptoms
Yes
No
Loose associations
Yes
No
Delusions
Yes
No
Hallucinations
Yes
No
Aggressive behaviors
Yes
No
Conduct problems
Yes
No
Oppositional behavior
Yes
No
Sexual dysfunction
Yes
No
Grief
Yes
No
Hopelessness
Yes
No
Social isolation
Yes
No
Worthlessness
Yes
No
Guilt
Yes
No
Elevated mood
Yes
No
Hyperactivity
Yes
No
Dissociative states
Yes
No
Somatic complaints
Yes
No
Self-mutilation
Yes
No
Major weight gain/loss
Yes
No
Emotional trauma victim
Yes
No
Physical trauma victim
Yes
No
Sexual trauma victim
Yes
No
Emotional trauma
Yes
No
Physical trauma
Yes
No
Sexual trauma
Yes
No
Substance abuse
Yes
No
Other Symptoms:
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EMOTIONAL/PSYCHIATRIC HISTORY
OUTPATIENT:
Any prior OUTpatient psychotherapy?
*
Please Select
Yes
No
Number of occasions?
*
Longest treatments were given by?
*
How many sessions?
*
Started around/about:
*
-
Month
-
Day
Year
Date
Ended around/about:
*
-
Month
-
Day
Year
Date
Has any family member(s) had OUTpatient psychotherapy?
*
Please Select
Yes
No
If yes, who and why?
*
EMOTIONAL/PSYCHIATRIC HISTORY
INPATIENT:
Any prior INpatient psychotherapy?
*
Please Select
Yes
No
Number of occasions?
*
Longest treatments were given by?
*
How many sessions?
*
Started around/about:
*
-
Month
-
Day
Year
Date
Ended around/about:
*
-
Month
-
Day
Year
Date
Has any family member(s) had INpatient psychotherapy?
*
Please Select
Yes
No
If yes, who and why?
*
Prior or current psychotropic medication usage?
*
Please Select
Yes
No
If, yes what medications are you currently taking?
*
Rows
Medication
Dosage
Frequency
Prescribed For
Beneficial?
1
5mg
10mg
20mg
30mg
40mg
50mg
60mg
70mg
80mg
90mg
100mg
100+ mg
Daily
2 times a day
3 times a day
Once a week
Yes
No
Sometimes
2
5mg
10mg
20mg
30mg
40mg
50mg
60mg
70mg
80mg
90mg
100mg
100+ mg
Daily
2 times a day
3 times a day
Once a week
Yes
No
Sometimes
3
5mg
10mg
20mg
30mg
40mg
50mg
60mg
70mg
80mg
90mg
100mg
100+ mg
Daily
2 times a day
3 times a day
Once a week
Yes
No
Sometimes
Has any of your family member(s) used psychotropic medication?
*
Please Select
Yes
No
Unsure
If Yes, who/why? (List all)
*
FAMILY HISTORY
Father's Name
*
Is your father deceased?
*
Please Select
Yes
No
Unsure
How old was patient when father died?
*
Father's Cause of Death:
*
Father's Occupation:
*
Father's Highest Education:
*
Please Select
Middle School
High School
Associates
Bachelors
Masters
Doctorate
Father's General Health:
*
Please Select
Perfect Health
Good Health
Mild Health
Bad Health
Mother's Name
*
Is your mother deceased?
*
Please Select
Yes
No
Unsure
How old was patient when mother died?
*
Mother's Cause of Death:
*
Mother's Occupation
*
Mother's Highest Education:
*
Please Select
Middle School
High School
Associates
Bachelors
Masters
Doctorate
Mother's General Health:
*
Please Select
Perfect Health
Good Health
Mild Health
Bad Health
Parent's current martial status:
*
Married to each other
Separated
Divorced
Mother remarried
Father remarried
Father/Mother involved with someone
Present during childhood:
*
Rows
Client Answer
Mother
Yes
No
not applicable
Father
Yes
No
not applicable
Stepmother
Yes
No
not applicable
Stepfather
Yes
No
not applicable
Brother(s)
Yes
No
not applicable
Sister(s)
Yes
No
not applicable
Special circumstances about client's childhood:
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IMMEDIATE FAMILY:
Marital status:
*
Please Select
Married
Divorced
Separated
Engaged
Not Dating
Notes
Are you in an intimate relationship
*
Please Select
Yes
No
Notes
How satisfied are you will this relationship?
*
Please Select
Very satisfied
Somewhat satisfied
Not satisfied
Notes
List all person(s) currently living in the client's household.
*
Rows
Name:
Age:
Sex:
Relation:
1
F
M
NB
2
F
M
NB
3
F
M
NB
4
F
M
NB
List all person(s) NOT living in the client's household.
*
Rows
Name:
Age:
Sex:
Relation:
1
Female
Male
Non-binary
2
Female
Male
Non-binary
3
Female
Male
Non-binary
4
Female
Male
Non-binary
Frequency of visitation:
Describe any past or current significant issues with intimate relationships:
Describe any past or current significant issues in immediate family relationships:
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MEDICAL HISTORY:
Describe current physical health:
Please Select
Perfect health
Good health
Mild health
Bad health
Note:
Name of Primary Care Physician:
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Name of Psychiatrist:
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Is there a history of any of the following in the family:
Tuberculosis
Heart disease
Birth defects
High Blood Pressure
Emotional problems
Alcoholism
Behavior problems
Drug abuse
Thyroid problems
Diabetes
Cancer
Alzheimer's disease/dementia
Mental retardation
Stroke
Any serious hospitalization(s) or accident(s)
Rows
Date
Age
Reason
1
2
3
4
5
Any known allergies?
*
Please Select
Yes
No
List allergies:
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SUBSTANCE ABUSE HISTORY:
Substance Abuse Used:
Rows
Used Before:
First Use Age:
Current Use:
Last Use Age:
Alcohol:
Yes
No
Yes
No
Amphetamines/speed:
Yes
No
Yes
No
Barbiturates/owners:
Yes
No
Yes
No
Caffeine:
Yes
No
Yes
No
Cocaine:
Yes
No
Yes
No
Crack Cocaine:
Yes
No
Yes
No
Hallucinogens (e.g., LSD):
Yes
No
Yes
No
Inhalants (e.g., glue, gas):
Yes
No
Yes
No
Marijuana/CBD/Hemp:
Yes
No
Yes
No
Nicotine/Cigarettes:
Yes
No
Yes
No
PCP:
Yes
No
Yes
No
Prescription Drugs:
Yes
No
Yes
No
Consequences of Substance Use:
Hangovers
Seizures
Blackouts
Overdose
Withdrawals Symptoms
Medical Conditions
Tolerance Changes
Loss of Control
Sleep Disturbance
Assaults
Suicide Impulse
Relationship Conflicts
Binges
Job Loss
Arrests
Other
Family Alcohol/Drug Abuse History
Father
Mother
Grandparent(s)
Sibling
Stepparent(s)
Uncle(s)/Aunt(s)
Spouse/Significant Other
Children
Other
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DEVELOPMENT HISTORY:
Is this assessment for a minor child?
*
Yes
No
Problems during mother's pregnancy:
*
None
High Blood Pressure
Kidney Infection
German measles
Emotional Stress
Bleeding
Alcohol Use
Drug Use
Cigarette Use
Other
Problems during birth:
*
Normal Birth
Difficult Birth
Cesarean Delivery
Other
Problems during infancy:
*
Feeding Problems
Sleeping Problems
Toilet Training Problems
Other
Delayed Development Milestones:
*
Sitting
Rolling over
Standing
Walking
Feeding self
Speaking words
Speaking sentences
Sleeping alone
Dressing self
Engaging peers
Tolerating separation
Playing cooperatively
Riding tricycle/bicycle
Controlling bladder
Controlling bowels
Other
Emotional/Behavioral Problems:
*
Drug use
Alcohol abuse
Chronic lying
Stealing
Violent temper
Hyperactive
Animal cruelty
Repeats words
Not trustworthy
Hostile/angry mood
Indecisive/Impulsive
Immature
Bizarre behavior
Self-injurious threats
Frequently tearful
Distrustful
Extreme worrier
Self-injurious acts
Easily distracted
Poor concentration
Often sad
Breaks things
Other
Social Interaction:
*
Normal social interaction
Isolates self
Very shy
Alienates self
Inappropriate sex play
Dominates others
Associates with acting-out peers
Other
Intellectual/Academic functioning:
*
Normal intelligence
Authority conflicts
High intelligence
Attention problems
Learning problems
Underachieving
Current or highest education level
Mild retardation
Moderate retardation
Severe retardation
Other
Current or highest education level:
*
Describe any other developmental problems or issues:
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SOCIO-ECONOMIC HISTORY:
Living Situation:
*
Social support system
Housing adequate
Homeless
Housing overcrowded
Dependent on others for housing
Housing dangerous/deteriorating
Living companions dysfunctional
Other
Social Support System:
*
Supportive network
Few friends
Substance-use-based friends
No friends
Distant from family of origin
Other
Military History:
*
Never in military
Served in military - no incident
Served in military - with incident
Other
Financial Situation:
*
No current financial problems
Large indebtedness
Poverty or below-poverty income
Impulsive spending
Relationship conflicts over finances
Other
Employment History:
*
Employed and satisfied
Employed but dissatisfied
Unemployed
Coworker conflicts
Supervisor conflicts
Unstable work history
Disabled
Other
Legal History:
*
No legal problems
Now on parole/probation
Arrest(s) not substance-related
Arrest(s) substance-related
Court ordered this treatment
Jail/prison _________time(s)
Total time served:
Describe last legal difficulty:
Other
Sexual History:
*
Heterosexual orientation
Homosexual orientation
Bisexual orientation
Currently sexually active
Currently sexually satisfied
Currently sexually dissatisfied
Age first sex experience
Age first pregnancy/fatherhood
History of promiscuity age
Other
Additional sexual history information:
Cultural/Spiritual/Recreational History
*
Cultural Identity (e.g. ethnicity, religion, etc.)
Describe any cultural issues that contribute to current problems:
Diagnostic Formulation/Recommendation:
SOCIO-ECONOMIC HISTORY:
Sources of Data Provided Above:
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