Initial Assessment Form | Smart's Solutions

Personal Information

This information is confidential. Please leave blank any questions you do not wish to answer.

First Name *

Last Name

Please share your pronouns

What is your gender

If Other please state

What is your sexuality

If Other please state

Is your gender different from the sex you were assigned at birth (are you trans)

If Other please state

Are you intersex?

If Other please state

Referred by

SelfGPMental health teamN/ASelect

If Other please state

Age

Date of birth

Number of children

Relationship status

Street Address

House/Flat/Apartment

City/Town

County

Postal Code

Phone Number

May I leave a message?YesNo

Email Address

May I email you?YesNo

Please list any prescription and over the counter medications you are taking?

Please list any psychiatric medications you have taken in the past:

Person to contact in an emergency

Phone

Are you currently receiving psychiatric and/or psychotherapy services?YesNo

Psychiatrist’s / Psychotherapist’s name:

OCCUPATION INFORMATION

Are you currently employed?YesNo

What is your current position?

Please list any employment-related stressors:

FAMILY HISTORY

Has any family member experienced any psychiatric problems?YesNo

If yes, please detail:

HEALTH INFORMATION

Are you experiencing any health concerns?

How would you rate your health? (please tick one)UnsatisfactorySatisfactoryGoodExcellent

Do you have sleep problems? (Describe)

Do you exercise?YesNo

If yes, how many times a week?

Do you drink alcohol?YesNo

If yes, how many units a week

In the do you use recreational drugs?YesNo

If yes, what type and how often per week

In the past year have you experienced any significant life stresses?

Please list your sources of emotional support:

What are your goals for therapy?

Anything else you think I should know?

Save as Draft