Today's Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date of Assessment*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Clinical ID #Client First Name*Client Last Name*Client Email Address Enter Email Confirm Email Client Phone NumberClient Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Current Age*Sex*MaleFemalePrefer Not To AnswerName of Person Completing Form* First Last Referral SourceReferral Source*Community ProviderCountyFamily/FriendLaw EnforcementMedical FacilitySchool/CollegeSelfCommunity ProviderPlease SelectAdult/Teen ChallengeAssociates in Psychiatry and PsychologyAttorneyBlue StemChemical Dependency FacilityCourtEAPEmployerEmpowerFamily Service RochesterGroup HomeIRTSNAMIOther CourtOther ProfessionalPhysicianPrairie CarePsychiatristPsychologistRecovery is HappeningVocational Rehab/Employment ServicesCountyPlease SelectBlue Earth CountyDodge CountyFillmore CountyGoodhue CountyHouston CountyMower CountyOlmsted CountyOlmsted County Social ServicesOther County AgencyParole OfficerRice CountySocial ServicesSocial WorkerSteele CountyWabasha CountyWaseca CountyWinona CountyFamily/FriendPlease SelectFamily/RelativeFriendLaw EnforcementPlease SelectBlue 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 FacilityPlease SelectAustin 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/CollegePlease SelectALCALC - APEXKingsland School DistrictOther School/CollegePine Island ElementaryPine Island High SchoolPine Island Middle SchoolRochester SchoolsSelfPlease SelectSelfAssessment OverviewPresenting Problem(s)/Reason for Assessment*When and how did the problem(s) start*Please select the symptoms you are having now*(select all that apply)Child symptoms onlyAches/painsAnxious/nervousAshamedBody image concernsCan't enjoy myselfChoking feelingCry easily/oftenDecreased appetite/weight lossDepressed/sadDifficulty breathingDistressing memoriesDisturbing thoughtsDizzinessElevated moodExcessive worryFeel inferiorFeel unworthyFeeling paranoid/suspiciousFrequent mood swingsGuilt feelingsHeadachesHear voicesHeart racingHeavy feelingHopelessnessIncreased appetite/weight gainIrritable/angryLack of motivationLonelinessLose temperLow energy/tiredLow self-esteemNightmaresNumbness/tinglingPoor concentrationPoor memoryRacing thoughtsRepetitive actionsRestless/fidgetySee images or objectsSelf harming behaviors/urgesSexual issues/concernsShakingSleep problemsSocial discomfortTense feelingsThoughts of wanting to dieThoughts of wanting to hurt othersViolent behaviorWound upOtherOther symptoms (please explain)*How have the problems/symptoms affected your life?*Areas that have been impaired by the symptoms:*(select all that apply)Coping skillsDaily living skillsEconomic/financial impairmentEducational/school functionHealthHousing/shelterLegal difficultiesMarital/family conflict or dysfunctionOccupational functioningSelf protection/personal safetySexual functioningSocializationOtherOther areas (please explain):*What have you already done on your own to help?*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:Name of medication:Dosage (if known):Reason for use (if known):Current or previous? Have you ever had thoughts or actions of suicide or self-harm? Or harming another person?*YesNoPlease explain:*List your strengths and vulnerabilities:*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/RelationshipAgeOccupationAlive? (yes/no) Are your parents divorced?*YesNoHow old were you at the time of the divorce?*Please complete the following information about your siblings, step-siblings, or half siblings (if applicable):Name/RelationshipAgeOccupationAlive? (yes/no) 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?*YesNoPlease explain.*Are you aware of any developmental problems or concerns from pre-birth/ childhood/ adolescence?*YesNoPlease explain.*Social/Relationship HistoryAre you currently married or in a relationship?*YesNoPlease 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?*Do you have any spiritual or cultural considerations you would like us to be aware of?*YesNoPlease explain.*Do you have a history of maltreatment and/ or abuse?*YesNoPlease explain.*What is your sexual orientation? Do you have any concerns with sexuality?*Education/Work HistoryHighest level of education:*Please SelectDid 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?*YesNoMedical 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:Name of medication:Dosage (if known):Reason for use (if known): Please list any important medical information (illnesses, injuries, surgeries, drug side effects):Do you have any allergies?YesNoPlease list all known allergies:Have you ever been hit in the head, or suffered head or brain trauma or injury?YesNoPlease explain:Chemical Use HistoryHave you ever used tobacco?YesNoPlease describe your tobacco use:Do you drink alcohol or use drugs?YesNoHow old were you when you started drinking alcohol or using drugs?What do you typically use and how much?Has your use ever concerned you or anyone else?YesNoPlease explain.Any negative consequences related to your use?YesNoPlease explain.Have you been treated for chemical use?YesNoWhere did you receive treatment for chemical use?Do you gamble?YesNoHas your gambling ever been a concern and/or caused problems for you?YesNoPlease explain.Have you been treated for a gambling addiction?YesNoWhere did you receive treatment for a gambling addiction?Please describe your family history of addictions or chemical dependency:Legal HistoryHave you ever been convicted of an offense or crime?YesNoPlease describe the offense or crime.Are you currently on probation or supervised prison release? Or have you been in the past?YesNoPlease explain why you were placed on probation or supervised prison release and provide the name of your Probation Officer or Supervising Agent.Have you been ordered by court/ probation/ parole for assessment, to attend therapy or treatment?Coordination of CarePlease list any other service providers that are assisting you:Do you have a Guardian or Conservator?YesNoGuardian or Conservator InformationFirst Name:Last Name:Phone Number: Please give any additional information that may be important or beneficial in your treatment:EmailThis field is for validation purposes and should be left unchanged.