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1 Adult Wellness Assessment Please take a few minutes to fill out this form. The information will be helpful in better understanding your individual needs and situation. Thank you. Personal Information Name: Age: Address: Phone: Spouse/Partner Name: Phone: Address: Briefly Describe the Reason for this Assessment Client History Client Place of Birth Raised by birthparents Birth Order Brothers ages Sisters ages Marriages for Mother Marriages for Father Parents are: Married - Separated Divorced Other - Your age at sep/div Client s present living situation: Home, Apartment, Other As a child were you ever been placed out of home: (No) (Yes) If so,when Where? For how long? Reason What is your current relationship like with your parents?
2 Other significant family information: (deaths, past trauma, family conflicts, jail time, etc) Additional Information that you would like your therapist to know: Support/Strengths Please list family, friends, support/community groups that are helpful to you: What are your favorite things to do? Name 3 things you do well. Name 3 things you don t do well Goals in life How do you feel about yourself? What things cause you stress What are your hobbies/favorite things to do? Who do you reach out to if you feel sad or hurt?
3 Developmental History Length of mother s pregnancy Complications No Yes (list) Did mother/father: smoke use alcohol street drugs Age when you: Walked Talked Toilet trained Went to school - easily - with difficulty - with mother - without mother Separation problems (e.g. significant people leaving child s life) Childhood Difficulties: If Any, (when, for how long, how was it resolved?) Fire-setting Cruelty to animals Violence/Hurting others Eating/appetite Sleeping (avoidance, talking in sleep, night) Nightmares (theme, frequency) Making friends Lying Stealing Hurting self Hyperactivity Grief/loss Psychosis Physical abuse Sexual Abuse Emotional abuse Suicide ideation/intent Homicide ideation/intent Unwanted intrusive thoughts Daydreams/periods of being spaced out Sexual issues/acting out Fearful Irritability Isolating Witness domestic violence/other trauma Additional Information
4 Work/ School History Present employment Do you like your job? How long have you been there? How far did you get in school? Are you considering returning to school? Additional Information Related to Work: _ Mental Health/Legal History Family history of mental health or substance problems Age when emotional difficulties began History of emotional challenges: Psychiatric Hospitalizations None - (who/when/where/why) Outpatient Therapy None - (therapist, length of time in Tx, when, response) Medication Use (past/present, length of time on med s) Name/telephone number of Primary Physician:
5 Legal History None Criminal CPS Family Court Are you on probation? Have you ever been to jail or prison? Explain Extended family legal history Do you have a history of substance use/abuse? Drugs Alcohol Other Please explain Have you been in drug rehab? When/Where Please list any suicide attempts (if none please write none) Previous or Current Counseling (if none write none) Additional Relevant Legal Information: Physical Health History Ht. Wt. Vision/hearing. Allergies Current health problems History of health problems-please Circle ( broken bones - injuries - accidents head injuries - periods of unconsciousness neurological problems seizures - hospitalizations - disease operations) - other Diet Exercise? Tobacco Substance use Last check-up Last dentist App Additional Information regarding physical health or history:
6 Current Challenges or Concerns: please check ( ) those that apply ( ) Difficulty falling asleep ( ) Change in appetite ( ) Waking in the night ( ) Gain or lose weight (specify ) ( ) Sleeping too much ( ) Not hungry or not eating ( ) Nightmares ( ) Throwing up after eating ( ) Moody or crying more than usual ( ) Feeling sick to stomach ( ) Difficulty concentrating ( ) Feeling guilty, worthless or hopeless ( ) Problems remembering things ( ) Fatigue low energy ( ) Withdrawing from others ( ) Hyper too much energy ( ) Repeated actions I can t stop ( ) Loss of interest in things ( ) People picking on me ( ) Depression ( ) Violence in family actual or threats ( ) Disturbing thoughts I can t stop ( ) Self harm ( ) I hear things that are not real ( ) I cut myself ( ) I see things that are not real ( ) I burn myself ( ) I feel/smell things that are not real ( ) Anxiety or panic attacks ( ) Death of a loved one ( ) Suicidal thoughts ( ) Employment problems ( ) Suicidal actions ( ) Parent-child conflict ( ) Sexual problem ( ) Marital problems ( ) Gambling ( ) Conflicted separation/divorce issues ( ) Sexual Abuse as an adult or child ( ) Legal problems ( ) Anger problems ( ) Communication problems Additional Information Related to the Above: Records Review (please attach copies of the following records) Record Type Comments Previous Mental Health Reports Law Enforcement Reports Court Ordered Mental Health Evaluations Relevant Medical reports Mediation Reports / 730 Evaluations Signature Client Name (please print): Date: Signature
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