Today's Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date of Assessment*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Clinical ID # Client First Name* Client Last Name* Client Email Address Enter Email Confirm Email Client Phone NumberClient Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Current Age* Sex* Male Female Prefer Not To Answer Name of Person Completing Form* First Last Referral SourceReferral Source* Community Provider County Family/Friend Law Enforcement Medical Facility School/College Self Community 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?* Yes No Please 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?* Yes No How 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?* Yes No Please explain.*Are you aware of any developmental problems or concerns from pre-birth/ childhood/ adolescence?* Yes No Please explain.*Social/Relationship HistoryAre you currently married or in a relationship?* Yes No 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?*Do you have any spiritual or cultural considerations you would like us to be aware of?* Yes No Please explain.*Do you have a history of maltreatment and/ or abuse?* Yes No Please 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?* No GED Diploma What 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?* Yes No 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: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? Yes No Please list all known allergies:Have you ever been hit in the head, or suffered head or brain trauma or injury? Yes No Please explain:Chemical Use HistoryHave you ever used tobacco? Yes No Please describe your tobacco use:Do you drink alcohol or use drugs? Yes No How 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? Yes No Please explain.Any negative consequences related to your use? Yes No Please explain.Have you been treated for chemical use? Yes No Where did you receive treatment for chemical use?Do you gamble? Yes No Has your gambling ever been a concern and/or caused problems for you? Yes No Please explain.Have you been treated for a gambling addiction? Yes No Where 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? Yes No Please describe the offense or crime.Are you currently on probation or supervised prison release? Or have you been in the past? Yes No Please 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? Yes No Guardian 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.
