Assessment Note

Client Name: Rika u Bahl | D.O.B.:  | Client Ac No.: 112022-00000-22 | 0000-00-00

Modality * Individual Couple Parents/ Guardian Family

Identifying Data

Male Female LGBTQ Other Married

Gender Identity* Relationship Status*

Living Arrangement* Siblings Spouse/ Partner Name kjkjkj

N/A No Yes nmnmnmnm

Children How Many & Ages

Employment/ Occupation

Employment Status* Part Time Occupation jjk

Veteran/ Military Service History Yes No Unknown

Presenting Problem*

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Approx Date of Onset of the Symptom* : 04-06-2022

History of Present Problem 

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Risk Factors

Denied Yes Suspected Denied Yes Suspected

Suicidal Ideation/ Behavior *  Past Suicidal Ideation/ Behavior *

Denied Yes Suspected Denied Yes Suspected

Violent Ideation/ Behavior *  Past Violent Ideation/ Behavior *

Other Significant Behavior Information Destruction of Property Cruelty to Animals Self-mutilation Firesetting Sexual Offense(s)


Comments

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History of Psychiatric Illness and Treatment

Psychiatric Medications * Denied Yes Unknown

Hospitalizations * Yes Denied

Comments

~‘!@#$%^&*()_+-={}[]|\:";’<>,.?/

Addictions/ Substance Abuse * Denied Yes

Denied Yes
Smoking Type and Quantity

Denied Yes
Alcohol Quantity/ Frequency

Denied Yes Cocaine

Illicit Drugs Which One(s)

Abuse of Prescription and/ or OTC Denied Yes

Details
Drugs

Denied Yes
Internet

Denied Yes
Gambling

Motivation to Address Substance Use Yes No Questionable

Problem(s)

Comments

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Legal Problems*  Denied Yes

Comments

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Psychosocial History

Early Growth and Development* 

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Personal History* 

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Educational/ Occupational History

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History of Abuse/ Trauma *  Denied Unknown Yes

Physical Sexual Emotional Domestic Violence Neglect

Abuse/ Trauma History

Victim Perpetrator Neither, but abuse/ trauma exists in the family Witness to abuse
Client is

In the past month, have you...

Had nightmares about the event(s) or thought about the event(s) when you did not want to? Yes No

Tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)? Yes No

Been constantly on guard, watchful, or easily startled? Yes No

Felt numb or detached from people, activities, or your surroundings? Yes No

Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused? Yes No

Comments

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If the client is under 18 year, the Clinician may be legally obligated to inform authorities. If Yes, steps taken :

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Family/ Current Home Environment 

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Psychiatric Illness in Biological Denied Yes

Family*

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Physical Health Status

Primary Care Physician Info

Send Consent Form To The Client

Allergies/ Adverse Reactions to Denied Yes Unknown

Medications

Significant Medical Challenges

None Serious infectious disease
Heavy substance use Thyroid Problem
Hypertension
Cancer
Genitourinary Problem

Mental Status Assessment *

Learning Needs

Self Care 

Assessment Notes

Diagnosis*

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