I. GENERAL INFORMATION

Full Name:

Phone Number:

Date of Birth:

Gender:MaleFemaleOther

II. PURPOSE OF ASSESSMENT(multiple options can be selected)

[checkbox purpose use_label_element multiple "Assess current emotional, behavioral, and mental health status" "Screen for developmental, self-learning, academic, or social interaction issues" "Health consultation, referral to a doctor or hospital" "School / organization / program requirements]

Other:

III. CURRENT SIGNS OR CONCERNS (select all that apply)

Emotional / Psychological:

Sadness, loss of interestFrequent anxiety or stressIrritability, difficulty controlling emotions
Other:

Behavior / Interaction:

Impulsive, easily agitatedDefiant, conflicts with othersReduced communication, social withdrawal
Other:

Development / Learning Issues:

Delayed speech / difficulty communicatingLearning difficulties / poor concentrationDeclining academic performance
Other:

Health / Physical / Eating Issues:

Fatigue / poor sleepLoss of appetite or overeatingBody aches, unexplained discomfort
Other:

Memory / Mood Issues:

ForgetfulnessSlowed thinking
Other:

Risk Behaviors:

Self-harmSuicidal thoughts or intentionsSubstance use / alcohol / tobacco
Other:

IV. PREVIOUS TREATMENT / ASSESSMENT HISTORY

Have previously seen a psychiatristHave previously received psychological therapyHave previously taken psychological assessmentsCurrently taking psychiatric medicationHave never accessed any services