DEMOGRAPHIC PROFILE
Name Date of Birth Age Gender
Address Birth Order Number of Siblings
Civil Status Occupation Religion Race/Ethnicity
Date of Evaluation
REASON FOR REFERRAL
PRESENTING PROBLEM
EDUCATIONAL HISTORY
Highest Educational Attainment:
Issues encountered while studying: Learning Behavioral Achievement Interpersonal.
Remarks related to the issues noted:
SOCIAL HISTORY
Where did the client grow up? Father’s occupation: Mother’s occupation:
Client’s relationship with parents, siblings, and other members:
Family situation that may have affected the client’s present functioning:
Experience of any early developmental problem as a child:
Experience being a victim of any form of physical/sexual/emotional abuse:
Experience of a romantic relationship:
Marital relationship, if married:
Remarks related to the client’s presenting problem:
PSYCHOLOGICAL & PHYSICAL HEALTH HISTORY
Past Mental Health Treatment
The client previously received counseling/psychotherapy?
No Yes, when and by whom?
The client is an outpatient treatment by a psychiatrist/psychologist?
No Yes, when and by whom?
List any psychiatric medication taken by the client (medication & date):
Medical History
List any medical problems encountered by the client:
List any serious medical procedures undergone by the client:
Identify if any medication problem has been encountered (complications, allergies, etc.)
Family Health History
List any history of illness (physical or mental) from the mother’s side:
List any history of illness (physical or mental) from the father’s side:
Remarks on the overall health status of the client:
I. The 4P Factor Model
FACTORS BIOLOGICAL SOCIAL PSYCHOLOGICAL
Predisposing
Precipitating
Perpetuating
Protective
MENTAL STATUS EXAMINATION
(Please check all that applies based on the assessment and put a remark if necessary)
A. PHYSICAL OBSERVATIONS
Appearance: Neat Inappropriate Disheveled Bizarre Other/s:
Speech: Normal Minimal Pressured Impoverished Other/s:
Eye Contact: Normal Intense Avoidant Intermittent Other/s:
Motor Activity: Normal Restless Tics Slowed Other/s:
Comments:
B. EMOTIONAL OBSERVATIONS
Affect Full Constricted Flat Labile Other/s:
Cooperative Evasive Uncooperative Threatening
Behavior
Agitated Combative Guarded Other/s:
Euthymic Anxious Angry Depressed Euphoric Irritable
Mood
Helpless Somber Sad Tearful Flat affect Other/s:
Comments:
C. COGNITIVE OBSERVATIONS
Consciousness: Alert Lethargic Stuporous Other/s:
Orientation Person Place Time and Day
Impairment: Current Situation Other/s: None
Coherent Tangential Circumstantial Loose
Thought Process:
Paranoid Concrete Other/s:
Normal Overvalued ideas Distortions
Thought Content: Hallucinations Rumination Delusions
Poverty of speech Other/s:
Persecutory Grandiose Referential
Delusions: Somatic Religious Bizarre
Erotomaniac Nihilistic None
Hallucinations: Auditory Visual Olfactory
Gustatory Tactile None
Insight: Good Fair Poor Limited Other/s:
Good Fair Poor Unrealistic
Judgment:
Unmotivated Uncertain None
For Self:
Ideation Plan Intent Attempt None
Risk Assessment:
For Others:
Ideation Plan Intent Attempt None
Comments:
Significant Findings:
Name of Evaluator:
Signature:
Date:
