Clinical Assessment

This assessment is designed to provide me with the greatest amount of information regarding you and your concerns in the shortest period of time. With a fuller understanding of you and your background, I can more readily address the specific concerns that you bring to counseling.

There are no right or wrong answers, please share whatever comes to mind.

If you feel strongly about not sharing certain information at this time, please omit it.

This is a comprehensive assessment, and may require up to half an hour to complete. It will best for you to complete the assessment at a time when you are unlikely to be disturbed. Although there is a long series of questions at the end, they only require a quick yes or no response.

Identification

Name:

E-mail:

Date of birth (dd/mm/yyyy):

What is your marital status?:

If you currently have a partner, what is their name?:

Sex: female male

Race/ethnic identity?:

Do you have any children? If so, what are their names and ages?

What is your current employment? How long have you been there?: years

Do you live alone or with someone?:

Do you have any religious affiliation?:

How did you find this site?

Presenting Problems

What problems and concerns bring you to counseling?:

Describe what motivated you to seek help at this time rather than some time in the past or future?:

How long have you been feeling this way? (for each feeling or problem)?:

What happened at the time you began feeling this way?:

When have you felt like this in the past and what happened?:

Since you have been feeling this way do you feel worse or better now?:

Assessment of Functioning

Describe your typical day. Please be as detailed as possible and include the people that you encounter.

Approximately how many hours per week do you spend doing the following?

Working:

Schoolwork (if applicable):

Parenting/caretaking of others:

Doing household chores, bills, etc.:

TV, movies:

Physical recreation and/or exercise:

Hobbies:

Social activity with friends, family:

Church, charity, spiritual, or inspirational activities:

Quiet, non-productive, or relaxing time:

Other: Please specify:

Average number of hours of sleep per night:

General History

Describe the worst time of your life.

Who helped you through it?

Are there things that you feel too ashamed to talk about or that would be difficult to talk about?

Describe the best time in your life.

Was there someone to share it with?

Do you have a close friend who is supportive and someone you can confide in during difficult times?

What are your strengths? How do you cope when times are hard?

Do you feel you are a person of worth at least on an equal basis to others?

Describe Your Past Medical/Counselling History:

Describe Your Family History and Relationships:

Describe Your Current Family Status and Relationships:

Personal History

Describe your birth and childhood development:

Describe your school and intellectual development:

Describe your social development:

Describe your occupational history:

Describe your hobbies and side interests:

Describe your sexual and marital history:

Describe your legal/debt difficulties:

Alcohol and Drug Abuse History

How much alcohol and/or drugs do you use and how often?

What are your reasons for using it?

How long have you used it and what changes have occurred if any?

Has your use of this gotten in the way or work or family and social relationships and responsibilities?

Has anyone ever objected to or commented about your drinking or use of drugs?

Functional Inquiry

What medications do you use? Why? How long?

Any changes in weight or appetite? Any dieting? Any vomiting?

Any problems getting enough sleep?

What has your energy level been like?

How would you describe your personality?

For the following, rate your level of satisfaction between one and ten.

How much enjoyment or pleasure are you currently getting out of living?:

General mood (depressed…happy):

Anxiety/tension (panic…relaxed):

Social relationships:

Family relationships:

Romantic relationships:

Daily work or school:

Have you ever had suicidal thoughts at any time in your life? How old were you? What happened?

Have you ever had thoughts of wanting to kill someone?

How has your memory been lately?

How well have you been concentrating lately?

Have you been able to make day-to-day decisions?

For the following respond yes or no.

Have you avoided jobs or tasks that involved having to deal with a lot of people?

Do you avoid getting involved with people unless you are certain they will like you?

Do you find it hard to be “open”, even with people you are close to?

Do you often worry about being criticized or rejected in social situations?

Are you usually quiet when you meet new people?

Do you believe that you’re not as good, as smart, or as attractive as most other people?

Are you afraid of trying new things?

Do you need a lot of advice or reassurance from others before you can make everyday decisions?

Do you depend on other people to handle important areas of your life such as finances, child care or living arrangements?

Do you find it hard to disagree with people even when you think that they are wrong?

Do you find it hard to start work on tasks even when there is no one to help you?

Have you often volunteered to do things that are unpleasant?

Do you usually feel uncomfortable when you are by yourself?

When a close relationship ends, do you quickly find someone else you can rely on?

Do you worry a lot about being left alone to take care of yourself?

Are you the kind of person who focuses on details, order, organization or likes to make lists and schedules?

Do you have trouble finishing jobs because you spend so much time trying to get things exactly right?

Do you (or others) feel that you are so devoted to work (or school) that you have no time for others or for fun?

Do you have very high standards about what is right and wrong?

Do you have trouble throwing things out because they might come in handy someday?

Is it hard to let other people help you unless they agree to do things exactly the way you want?

Is it hard for you to spend money on yourself and other people even when you have enough?

Are you often so sure that you are right that it doesn’t matter what other people say?

Have other people told you that you are stubborn or rigid?

When someone asks you to do something that you don’t want to do, do you then work slowly or do a bad job?

Often, if you don’t want to do something, do you just “forget” to do it?

Do you often feel that other people don’t understand you, or don’t appreciate how much you do?

Are you often grumpy and likely to get into arguments?

Have you found that most of your bosses, teachers, doctors, and others who are supposed to know what they are doing, really don’t?

Do you often think that it’s not fair that other people have more than you do?

Do you often complain that more than your share of bad things have happened to you?

Do you angrily refuse to do what others want and then later feel bad and apologize?

Do you usually feel unhappy or like life is no fun?

Do you believe that you are basically an inadequate person and often don’t feel good about yourself?

Do you often put yourself down or blame yourself for things that haven’t worked out?

Are you a worrier?

Do you often judge others harshly and easily find fault with them?

Do you think that most people are basically no good?

Do you almost always expect things to turn out badly?

Do you often feel guilty about things you have or haven’t done?

Have you repeatedly been involved with friends or lovers who have taken advantage of you or let you down?

Have you sometimes gotten into bad situations where you wound up being taken advantage of?

Do you often refuse help from other people because you don’t want to bother them?

When people try to help you, do you find it hard to accept or do you make it hard for them to help you?

When you are successful, do you feel depressed or like you don’t deserve it, or do something to spoil it?

Do you often turn down the chance to do things that you really enjoy?

Do you often have to keep an eye out to stop people form using you or hurting you?

Do you spend a lot of time wondering if you can trust your friends or the people you work with?

Do you find that it is best not to confide in others because they will use it against you?

Do you pick up hidden threats or insults in what people say or do?

Are you the kind of person who holds grudges or takes a long time to forgive when insulted or slighted?

Are there many people that you can’t forgive because they did or said something to you a long time ago?

Do you often get angry or lash out when someone criticizes or insults you in some way?

Have you often suspected that your spouse or partner has been unfaithful?

When you are out in public and see people talking, do you often feel that they are talking about you?

Do you often feel that things that have no special meaning to most people are really meant to give you a message?

Do you often detect hidden messages in seemingly unrelated events?

Have you ever felt that you could make things happen just by making a wish or thinking about them?

Have you had personal experiences with the supernatural?

Do you believe you have a “sixth sense” that allows you to know or predict things that others can’t?

Do you often think that objects or shadows are really people or animals or that noises are actually voices?

Have you had the sense that some person or force is around you, even though you cannot see anyone?

Do you often see auras or energy fields around people?

Are there very few people that you are really close to outside your immediate family?

Do you often feel nervous when you are with other people?

Is it NOT important to you whether you have any close relationships, including being part of a family?

Would you almost always rather do things alone than with other people?

Could you be content without ever being sexually involved with another person?

Are there really very few things that give you a lot of pleasure?

Does it not matter to you what people think of you?

Do you find that nothing makes you very happy or very sad?

Are you uncomfortable if you are not the center of attention?

Do you flirt a lot?

Do you often find yourself “coming on” to people?

Do you try to draw attention to yourself by the way you dress or look?

Do you often make a point of being dramatic or colorful?

Do you often change your mind about things (opinions) depending on the people you’re with or what you have just read or seen on TV?

Do you often have lots of friends that you are very close to?

Do most people fail to appreciate your very special talents or accomplishments?

Have people told you that you have too high an opinion of yourself?

Do you think a lot about power, fame, or recognition that will be yours someday?

Do you think a lot about the perfect romance that will be yours someday?

When you have a problem, do you almost always insist on seeing the top person?

Do you feel it’s important to spend time with people who are special or influential?

Is it very important to you that people pay attention to you or admire you in some way?

Do you think that it’s not necessary to follow certain rules or social conventions when they get in your way?

Do you feel that you are the kind of person who deserves special treatment?

Do you often find it necessary to step on a few toes to get what you want?

Do you often have to put your needs above other people’s?

Do you often expect other people to do what you ask without question because of who you are?

Are you NOT really interested in other people’s problems or feelings?

Are you often envious of others?

Do you feel that others are often envious of you?

Do you find that very few people are worth your time and attention?

Have you often become frantic when you thought that someone you really cared about was going to leave you?

Do your relationships with people you really care about have a lot of extreme ups and downs?

Have you abruptly changed your sense of who you are and where you are headed?

Does your sense of who you are often change dramatically?

Have there been lots of sudden changes in your goals, career plans, religious beliefs., and so on?

Have you often done things impulsively (spending, sex, reckless driving)?

Have you tried to hurt or kill or threatened to do so?

Have you ever cut, burned, or scratched yourself on purpose?

Are you a “moody” person?

Do you often feel empty inside?

Do you often have temper outbursts or get so angry that you lose control?

Do you hit people or throw things when you get angry?

Do even little things get you very angry?

When you are under a lot of stress, do you get suspicious of other people or feel especially spaced out?

Before the age of 15 did you ever do any of the following:

Did you bully or threaten other kids?

Did you start fights?

Did you hurt or threaten someone with a bat, brick, broken bottle, knife, or gun?

Did you ever deliberately try to cause someone physical pain and suffering?

Did you torture or hurt animals on purpose?

Did you ever rob, mug or forcibly take something from someone by threatening him or her?

Did you ever force someone to have sex with you?

Did you set fires?

Did you deliberately destroy things that weren’t yours?

Did you ever break into a house, other buildings, or cars?

Did you lie a lot or “con” other people?

Did you sometimes steal, shoplift things or forge someone’s signature?

Did you run away from home and stay away overnight?

Would you often stay out late, long after the time you were supposed to be home?

Did you often skip school?

Is there anything else that you would like to add that you feel is relevant?

Having reviewed all of this information, I’m wondering if you might have a little bit of insight or some understanding of the story behind the information you’ve just shared and your current concerns?

Considering all of this information, what are your goals for counseling?

How has it been for you, sorting through all of this information?