subject_line
HOPE PSYCHOLOGY GROUP INC. NEW ADULT EVALUATION FORM
SYMPTOM/SCALE RATING
PLEASE ANSWER ALL THE QUESTIONS ON ALL THE PAGES IN THIS PACKET AND HAVE YOUR INSURANCE CARD READY.
Please check any of the symptoms that apply and please rate your discomfort on a scale of 0-10, with 0 meaning there is NO distress and 10 meaning there is a great deal of distress.
I read and understand
Symptoms
*
Depressed/sad mood
0
1
2
3
4
5
6
7
8
9
10
Thoughts of hurting yourself/others
0
1
2
3
4
5
6
7
8
9
10
Anxious mood
0
1
2
3
4
5
6
7
8
9
10
Unusual thoughts
0
1
2
3
4
5
6
7
8
9
10
Drug/Alcohol issues
0
1
2
3
4
5
6
7
8
9
10
Relationship or family problems
0
1
2
3
4
5
6
7
8
9
10
Work problems or academic issues
0
1
2
3
4
5
6
7
8
9
10
Anger management problems
0
1
2
3
4
5
6
7
8
9
10
Grief issues
0
1
2
3
4
5
6
7
8
9
10
Symptoms
*
Inattention/distracted
0
1
2
3
4
5
6
7
8
9
10
Confusion
0
1
2
3
4
5
6
7
8
9
10
Physical complaints
0
1
2
3
4
5
6
7
8
9
10
Insomnia
0
1
2
3
4
5
6
7
8
9
10
Impulsive behaviors
0
1
2
3
4
5
6
7
8
9
10
Memory impairments
0
1
2
3
4
5
6
7
8
9
10
Abuse issues
0
1
2
3
4
5
6
7
8
9
10
Physical aggression issues
0
1
2
3
4
5
6
7
8
9
10
Sexual issues
0
1
2
3
4
5
6
7
8
9
10
Others:
What is the concern that has prompted
you to seek assistance?
*
Have you sought help for this concern
in the past? If so, what worked or did
not work?
*
Have you ever had an injury or concussion?
Yes or No?If yes, what age? Did you had
treatment for that injury?
*
What is your expectation from therapy?
*
How were you referred to us?
*
Do we have permission to contact the person who referred you?
*
Yes
No
Client's Name:
*
Date:
*
+