Client Assessment and Success plan
Progress: 
 
1.
Please enter the information indicated below.

First Name:
Last Name:
Home Phone:
Email Address:
emailaddress@xyz.com

2.

Birth Date 

 

50 characters left.
3.

List emergency contacts

 

1000 characters left.
4.

Preferred Pronouns: 

she/her/hers
he/him/his
they/them/theirs
ze/hir
Just my name
Other  
5.

Marital status

never married
partnered
married
seperated
divorced
widowed
6.

Number of children

 

50 characters left.
7.

Tell us about your children (age, status, school, names, etc.)

 

350 characters left.
8.

Are you currently receiving psychiatric services, professional counseling, or psychotherapy elsewhere? If yes, please list:

yes
no
  • Comment:

  • 500 characters left.
9.
Are you currently take prescribed psychiatric medications (antidepressants or others)?Iif yes please list:
yes
no
10.

Have you been previously prescribed psychiatric medication? If yes please list:

yes
no
  • Comment:

  • 500 characters left.
11.

Do you have transportation?

yes
no
HEALTH AND SOCIAL INFORMATION
 
12.
How is your physical health at present?
poor unsatisfactory satisfactory good very good       
      
13.

Please list any persistent physical symptoms or health concerns (e.g. chronic pain, headaches ,hypertension, diabetes, etc.):

 

350 characters left.
14.

Do you regularly consume alcohol?

yes
no
15.

In a typical month, how often do you have 4 or more drinks in a 24-hour period?

 

50 characters left.
16.

How often do you engage in recreational drug use?

daily
weekly
monthly
rarely
never
17.

Have you had suicidal thoughts recently?

frequently
sometimes
rarely
never
18.

Have you had them in the past?

frequently
sometimes
rarely
never
19.

In the last year have you experienced any significant life changes or stressors? 

 

350 characters left.