Today's Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date of Assessment*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Clinical ID #Client First Name*Client Last Name*Client Email Address Enter Email Confirm Email PhoneDate of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Current Age*Sex*MaleFemalePrefer Not To AnswerName of Person Completing Form* First Last Referral SourceReferral SourceCommunity ProviderCountyFamily/FriendLaw EnforcementMedical FacilitySchool/CollegeSelfCommunity ProviderCommunity ProviderAdult/Teen ChallengeAssociates in Psychiatry and PsychologyAttorneyBlue StemChemical Dependency FacilityCourtEAPEmployerEmpowerFamily Service RochesterGroup HomeIRTSNAMIOther CourtOther ProfessionalPhysicianPrairie CarePsychiatristPsychologistRecovery is HappeningVocational Rehab/Employment ServicesCountyCountyBlue Earth CountyDodge CountyFillmore CountyGoodhue CountyHouston CountyMower CountyOlmsted CountyOlmsted County Social ServicesOther County AgencyParole OfficerRice CountySocial ServicesSocial WorkerSteele CountyWabasha CountyWaseca CountyWinona CountyFamily/FriendFamily/FriendFamily/RelativeFriendLaw EnforcementLaw EnforcementBlue Earth County Sheriffs DepartmentDodge County Sheriffs DepartmentFillmore County Sheriffs DepartmentGoodhue County Sheriffs DepartmentHouston County Sheriffs DepartmentLaw Enforcement AgencyMN Dept of CorrectionsMower County Sheriffs DepartmentOlmsted County Sheriffs DepartmentRice County Sheriffs DepartmentRochester Police DepartmentSteele County Sheriffs DepartmentWabasha County Sheriffs DepartmentWaseca County Sheriffs DepartmentWinona County Sheriffs DepartmentMedical FacilityMedical FacilityAustin Medical CenterCommunity Behavioral HospitalMayo ClinicMayo Health SystemMental Health AgencyNursing HomeOlmsted Medical CenterOther Hospital/Medical CenterRapid Access ClinicSt. Mary's Hospital/Generose/MayoVeteran's HospitalVeteran's ServicesSchool/CollegeSchool/CollegeALCALC - APEXKingsland School DistrictOther School/CollegePine Island ElementaryPine Island High SchoolPine Island Middle SchoolRochester SchoolsSelfSelfAssessment OverviewPresenting Problem(s)/Reason for Assessment*When and how did the problem(s) start*Please check the symptoms you are having now Aches/pains Anxious/nervous Ashamed Blames others Body image concerns Can't enjoy myself Choking feeling Cry easily/often Depressed/sad Destroys property/fires Difficulty breathing Distressing memories Disturbing thoughts Dizziness Eating/appetite concerns Elevated mood Excessive worry Feel inferior Feel unworthy Feeling paranoid/suspicious Forgetful Frequent mood swings Frustration Guilt feelings Headaches Hear voices Heart racing Heavy feeling Hoarding Hopelessness Hyperactivity Impulsive Irritable/angry Lack of motivation Lies/steals Loneliness Lose temper Low energy/tired Low self-esteem Motor or verbal tics Nightmares Numbness/tingling Physical aggression/cruelty to animals Poor concentration Poor memory Racing thoughts Repetitive actions Restless/fidgety See images or objects Self harming behaviors/urges Sexual issues/concerns Shaking Sleep problems Social discomfort Tense feelings Thoughts of wanting to die Thoughts of wanting to hurt others Wound up Other symptoms (please explain)How have the problems/symptoms affected your life?Areas that have been impaired by the symptoms: Coping Skills Daily living skills Economic/financial impairment Educational/school function Health Housing/shelter Legal difficulties Marital/family conflict or dysfunction Occupational functioning Self protection/personal safety Sexual functioning Socialization Other areas (please explain):What have you already done on your own to help?*Chemical Use HistoryHave you ever used tobacco? If yes, please describe your use:If you drink alcohol or use drugs, how old were you when you started?What do you typically use and how much?Has your use ever concerned you or anyone else? Any negative consequences related to your use?Do you gamble? If yes, has your gambling ever been a concern and/or caused problems for you?Where have you been treated for chemical use? Or a gambling addiction?Please describe your family history of addictions or chemical dependency:Medical HistoryWho is your healthcare provider?When was your last physical exam?Describe any current medical problems or physical symptoms you are having:List any medications you are taking (Please include dosages and reason for use if known):Please list any important medical information (illnesses, injuries, surgeries, drug side effects):Do you have any allergies? If yes, please list:Have you ever been hit in the head, or suffered head or brain trauma or injury? If yes, please explain:Mental Health HistoryPlease list previous mental health services (include therapy, psychiatry, hospitalizations, commitments, county services, etc):Date of service:Where were you seen/treated:Focus of treatment: List current and previous medications you have been prescribed for mental health or psychiatric reasons (Please include dosages and reason for use if known):Have you ever had thoughts or actions of suicide or self-harm? Or harming another person?List your strengths and vulnerabilities:Triggers and warning signs for relapse:Social/Relationship HistoryAre you currently married or in a relationship? Please provide partner's name and length of relationship:Strengths in relationship?Problems in relationship?Any previous marriages or significant relationships?Please complete the following information about your children or step-children: (if applicable)NameSexAgeLiving with you?Additional Information Who is supportive of you or where do you get your support?Coping skills:Current living situation:Do you have any spiritual or cultural considerations you would like us to be aware of?Do you have a history of maltreatment and/ or abuse?What is your sexual orientation? Do you have any concerns with sexuality?Education/Work HistoryHighest level of education:Did not graduate high schoolHigh SchoolSome collegeBachelor's DegreeMaster's DegreeDoctoral DegreeDo you have a diploma or GED?NoGEDDiplomaWhat is or was school like for you? Were you ever on Truancy or an Individual Education Plan (IEP)?Where are you currently working and how long have you been there?Please describe your employment history:Have you been in the military?YesNoLegal HistoryHave you ever been convicted of an offense or crime? If yes, please provide more information.Are you currently on probation or supervised prison release? Or have you been in the past?If yes, for what? Please provide name of Probation Officer or Supervising Agent.Have you been ordered by court/ probation/ parole for assessment, to attend therapy or treatment?Family HistoryWhere were you born and where did you grow up?By whom were you raised? What was it like growing up in your family?Was there any violence in your family (verbal, emotional, sexual, physical)?Please provide the following information about your parents or step-parents:Name, Relationship, Age, Occupation, Alive? (Yes/No)If your parents were divorced, how old were you at the time?Please describe your current relationships with your parents and siblings:Have any of your family members been treated for or diagnosed with a mental illness? Please explain.Are you aware of any developmental problems or concerns from pre-birth/ childhood/ adolescence?Coordination of CarePlease list any other service providers that are assisting you:Do you have a Guardian or Conservator? If yes, please list the name and contact information:Please give any additional information that may be important or beneficial in your treatment:Would you like a copy of this form emailed to you? Enter Email Confirm Email Enter your email and we will send you a copy of the form.NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.