Initial Assessment Questionnaire

Note: Please feel free to attach answers if more space is needed.

Name:

Date of Birth:

Today's Date:

Address:

Email Address:

Home Phone:

Work Phone:

Cell Phone:

Best Number To Reach You At:

May We Leave A Message At This Number And/Or Text, Email You?

Employer:

Position/Title:

Length of Employment:

Are you satisfied with your work? If not, why?

Highest level of education completed:

Who do you live with, if anyone?

Marital Status:

If not married, are you in a committed relationship?

Length of time in current relationship:

Sexual Orientation:

Do you have children, and if so what are their ages?

How would you describe the interactions and relationships with each of your family members including family of origin?

Where were you raised?

Do you have close friends?

Do you have relationships with friends from your past?

What is your history with your co-workers?

How do you like to spend your free time?

Do you have any current or historic use of drugs?

Types of drugs used:

Frequency of drug use:

Any prescription drugs taken - please list all prescription medications currently taken:

Alcohol use. How often do you have an alcoholic drink?

How many drinks per week do you consume?

Have you ever had blackouts after drinking?

Have you ever been diagnosed with a substance abuse problem?

Have you ever seen a therapist?

If so, who did you see, for what issue and for how long did the therapy last?

Did you consider the therapy successful?

Have you ever been hospitalized for any substance abuse or mental health issues?

Have you ever been diagnosed with any mental health problems?

Have you ever felt suicidal?

Have you ever attempted to commit suicide?

What are your biggest stressors?

Have you ever had a panic attack?

Would you describe yourself as an angry person?

Do you often cry?

Do you know why you cry?

What is the quality and duration of your sleep?

How is your appetite?

Do you have problems with food (binge eating, any history of anorexia)?

Do you have a primary physician?

Name and phone number:

What was the date of your last visit?

Do you have any health issues?

Do you exercise?

How often, what do you do?

Are you a spiritual person?

Are you a religious person?

What is your religion?

Do you attend a place of worship regularly?

Why have you decided to come in to speak with me today?

What would you like to be different in your life?

Download: Divorce Group Work Application

Initial Assessment Questionnaire

Initial Assessment Questionnaire

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