Adult Psych Eval Packet

Adult Psych Eval

Welcome! Thank you for choosing Northeast Rehab Therapy Services.

Therapy is essentially a journey into bringing out the best in yourself. If this is your first experience with therapy, you might feel a bit nervous or apprehensive. This is normal!

Therapy is a process that allows you the freedom and privacy to discuss issues that are often painful or difficult to discuss with family or friends. Together we will discover and help to maximize your strengths as well as identifying and working on your limitations.

The first session will be more of an interview process for the physician to get to know you and work with you to develop a treatment plan best suited to you and your goals.

To assist in this process, please complete the questionnaire below prior to your first appointment. You do not need to print. Once you complete and click submit, our office will securely receive your responses.

Also, before your appointment, consider writing down questions, topics, or issues you would like to focus on in your sessions.

To ensure we are providing quality care, we need information from you and need to provide you with information about our practice policies. Below are links to our practice policies. Please click on each one to review prior to your visit. When you arrive for your appointment, you will be asked to electronically sign that you have reviewed and understand them.

Forms to be completed:

Medication intake form

Policies to view only

To provide you with secure electronic access to our physicians and staff, Northeast Rehab utilizes a Patient Portal. You need an access code to register. Once you receive your access code, you can click here to register. Through our patient portal, you can request appointments, update your medical history, medications, and allergies, and send a note to your provider. We encourage you to sign up for the Patient Portal before your first visit.

Patient History

First Name(Required)

Last Name(Required)

Date of Birth(Required)

Age(Required)

Primary Care Provider(Required)

Email(Required)

What are your concerns that bring you to therapy?(Required)

Childhood History

Where were you born and raised?(Required)

How was your relationship with your parents/caregivers?(Required)

Do you have any siblings?(Required)

How many?(Required)

Ages?

How would you describe your childhood?(Required)

Education

How far did you go in school?

Any learning disabilites, special education classes, suspensions, expulsions, or repeated grades?(Required)

If yes, please explain:

Social History

What is your current relationship status?(Required)

Any previous marriages?(Required)

How long in last relastionship?

Are you satisfied with the relationship?(Required)

Please Explain:

With whom do you live now?(Required)

Do you have any children?(Required)

If so, how many?

Ages?

Are you currently working?(Required)

What was your current/last job?(Required)

Have you served in the military?(Required)

If yes, rank and duration:

Are you able to work/continue to work at this time?(Required)

If not, why?(Required)

Medical History

Do you or have you had any problems with the following: (Check all that apply)(Required)

Past Work Injury Date(Required)

Motor Vehicle Accident Date(Required)

How much over how long?(Required)

List Surgeries and Dates:

Medication History

Who prescribes your medication?(Required)

Do you have difficulty remembering to take your medications?(Required)

Do you take as prescribed?(Required)

If not, explain:

Mental Health Treatment History

Have you ever had mental health treatment?(Required)

Diagnosis?(Required)

Provider?(Required)

When?(Required)

How long in treatment?

Are you currently in treatment?(Required)

With whom?

How Long?(Required)

Diagnosis?(Required)

Have you ever been to a psychiatric hospital?(Required)

Voluntary?(Required)

Reason:(Required)

Dates:(Required)

History of Suicidal Attempts(Required)

Current Suicidal Thoughts?(Required)

Curent Homicidal Thoughts?(Required)

Any History or Trauma/Abuse:(Required)

Substance Use History

History of substance abuse?(Required)

If so, what type of substance(s)?(Required)

What age did you start?(Required)

How often did you use?(Required)

How much did you use?(Required)

Current substance abuse? Including prescription drugs or alcohol?(Required)

Family history of psychiatric illness including dementia and substance abuse?(Required)

Legal History

Have you ever been arrested?(Required)

When?

Why?

How long in jail?

Mental Health Status

How would you describe. your mood most of the time?(Required)

Do you experience any of the following: