1. Adult Assessment form 1. Adult Assessment Full Name * Date * Phone Number * Email Address * Marital Status * Single Married Separated Divorced Widowed Cohabitating If you are living with someone, what is the quality of that relationship? * Good Fair Poor Not Living with Anyone Are you employed? * Yes No What is your occupation? * What brings you to counseling? (Check all that apply) * Depression Family Job Anxiety Stress Grief Marital / Relationship Alcohol / Drugs Criminal Charges How severe is this issue? * Mild Moderate Severe Disabling How long have you been dealing with this? * Are you experiencing any of the following? (Check all that apply) * Guilt Trouble Sleeping Memory Problems Worry Loss of Interest Weight Gain Weight Loss Trouble Concentrating Panic / Extreme Nervousness Fatigue Feeling Hopeless Feeling Helpless Anger Irritability Are you presently taking any medication? * Yes No What medication / dose and for how long? * Add another medication? * Yes No What medication / dose and for how long? * Have you ever had counseling before? * Yes No What for, where and when? * If you drink, would you describe yourself as being: * Social Drinker Problem Drinker Binge Drinker Alcoholic Not Applicable Has anyone ever told you they thought you might have a problem with alcohol? * Yes No Have you ever had treatment for alcohol problems? * Yes No Where and when? * If you use illicit drugs, would you describe yourself as being: * Recreational User Problem User Addicted Not Applicable Has anyone ever told you they thought you might have a problem with illicit drugs? * Yes No Have you ever had treatment for prescription or illicit drug abuse? ? * Yes No Where and when? * Do you have any relatives with a history of emotional issues, alcohol abuse, and/or prescription or illicit drug abuse? * Yes No If yes, who and what kind of issues? * Do you presently have any involvement with the legal system? * Yes No Please describe: * Is there anything else about you that might be helpful to the counseling process? reCAPTCHA If you are human, leave this field blank. Submit Δ Contact Me TODAY. I'D LOVE TO HEAR FROM YOU. *I am not currently accepting new clients but can add you to our waiting list. Contact Us Full Name * Phone Number * Email * Reason for Contacting (Select One) * General QuestionHelp With FormsNew Client Inquiry (Add Me to Waiting List)Other Reason for Contacting (Select One) Message * reCAPTCHA If you are human, leave this field blank. Submit Δ
