Psychological Evaluation Form
All questions contained in this questionnaire are strictly confidential and will become part of the patient’s
medical record.
Date of Evaluation: _______________
Personal Information
• Full Name: __________________________________________________________________
• Date of Birth: _______________________________________________________________
• Age: _______________________________________________________________________
• Gender: ____________________________________________________________________
• Marital Status: ______________________________________________________________
• Contact Information:
o Phone: _________________________________________________________________
o Email: __________________________________________________________________
o Address: ________________________________________________________________
Referral Information
• Referred By: ________________________________________________________________
• Reason for Referral: _________________________________________________________
• Previously Seen by Another Doctor?
o □ Yes □ No
o If yes, provide details (e.g., name, specialty, reason): __________________________
_________________________________________________________________
Presenting Problem
• Describe your current difficulties or concerns: _________________________________
____________________________________________________________________________
• When did these problems begin?: ______________________________________
• Have they worsened, improved, or stayed the same?: _____________________
• What triggers or worsens the problems?: _______________________________
• What helps or relieves the problems?: __________________________________
Psychiatric History
• Have you ever been diagnosed with a mental health condition?
o □ Yes □ No
o If yes, specify: ____________________________________________
• Have you received any psychiatric treatment in the past?
o □ Yes □ No
o If yes, list treatments (e.g., therapy, hospitalization): ______________________________
• Current Medications (Include dosages): _________________________________
_________________________________
• Past Medications (Include effectiveness): _________________________________
_________________________________
• Any previous suicide attempts or self-harm behaviors?
o □ Yes □ No
o If yes, explain: _____________________________________________
Medical History
• Do you have any chronic medical conditions?
o □ Yes □ No
o If yes, specify: ____________________________________________
• Do you take any regular medications?
o □ Yes □ No
o If yes, list them: ___________________________________________
• Have you experienced head injuries, seizures, or other neurological issues?
o □ Yes □ No
o If yes, explain: _____________________________________________
• Date of last physical examination: ___________________________
• Allergies (medication, food, environmental):
o □ Yes □ No
o If yes, specify: ____________________________________________
• Surgical History (Include dates and types of surgeries):
• Do you use alcohol or recreational drugs?
o □ Yes □ No
o If yes, describe frequency and type: ___________________________
Family History
• Is there a family history of mental health conditions?
o □ Yes □ No
o If yes, specify: ____________________________________________
• Family history of substance abuse?
o □ Yes □ No
o If yes, explain: _____________________________________________
• Any history of family conflicts or trauma?
o □ Yes □ No
o If yes, describe: ____________________________________________
Developmental and Social History
• Were there any developmental delays in childhood?
o □ Yes □ No
o If yes, specify: ____________________________________________
• Describe your relationships with family members: _________________________________
• Do you have close friends or a support network?
o □ Yes □ No
• Are you currently working or studying?
o □ Yes □ No
o If yes, specify occupation or course: _________________________
• Any major life events or trauma (past or recent)?
Behavioral and Emotional Symptoms
• Check all that apply:
o □ Depressed mood
o □ Anxiety or excessive worry
o □ Irritability or anger
o □ Sleep problems (too much or too little)
o □ Difficulty concentrating
o □ Low energy or fatigue
o □ Appetite changes (increase or decrease)
o □ Panic attacks
o □ Hallucinations or delusions
o □ Paranoia or suspiciousness
o □ Impulsive behaviors
o □ Self-harm thoughts or behaviors
o □ Suicidal thoughts
o □ Other: _____________________________________________
Goals for Assessment or Treatment
• What do you hope to achieve from this assessment or treatment?
Consent and Signature
I confirm that the information provided is accurate to the best of my knowledge.
Signature: _____________________________ Date: _______________
Clinician Notes (to be completed by assessor):
