ADULT INITIAL ASSESSMENT
Client Name: _________________________________ Date: ________ Start/End Time: ______________
Other attendees/relationship: _______________________________________________________________
______________________________________________________________________________________
Client DOB: ________ Age:_____ Gender: __ Preferred phone number: ________________________
Occupation: _______________________________ Employer: ____________________________________
I. Presenting Problem
Client’s description of the presenting problem(s) including precipitating factors, history of problem, and
attempted solutions:
Previous mental health issues/treatment:
□ releases obtained
II. Risk Assessment
Suicide risk:
Notes:
Danger to others:
Notes:
□ Denies
□ Ideation
□ Intent
□ Plan
□ Attempt
□ Denies
□ Ideation
□ Intent
□ Plan
□ Attempt
III. Partner Relationships/Family (genogram on back of this page)
Marital history (# of marriages, dates, how they ended, other long-term romantic relationships)
Current relationship status and partner info (name, age, occupation, married/engaged/cohabitating, other
significant information)
Current living situation: (circle one) Own
Rent
Homeless
Other: ___________
Other non-partner adults in the home?
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Children in the home (names, ages, relationships)
Other biological children not living with client (names, ages, reason for other placement)
Family of origin (relationship with parents in childhood, current relationship with parents, parents’
occupations and personalities, relationship past and present with siblings, birth order, dates and age of any
deceased family members- cont. on back if necessary)
Cont. on back? YES NO
IV. Health
Last physical exam ______
Doctor’s name ______________
Medical history (illnesses, accidents, medications, current health status)
Currently compliant in taking medications as prescribed? If not, why?
Substance abuse: (alcohol, drugs, age of first use, frequency, family history, symptoms, consequences, tx)
What is the client’s caffeine intake?
Does client smoke cigarettes? (If yes, specify history and current use.)
Family health history
Family mental health history (including institutionalizations, ADHD-type problems, anyone “not quite right”)
V. Personal
Recent major changes/losses ( divorce, death, job, relocation, etc.)
Employment (past, present, disruptions, aspirations)
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Education (trouble with learning, attention, behavior, learning disabilities, truancy as child/adolescent, highest
grade completed, adult educational history, future plans)
Military service (branch, length and location of service, active duty, time at war, type of discharge)
Legal problems (past or pending, criminal, nature, attitude toward authority)
Abuse (physical/sexual/verbal/emotional, perpetrator or victim, if victim: by whom, age(s), duration,
frequency, reactions, current attitude about the abuse) or other trauma
VI. Resources
Current support system (friends, family, pets, social groups, religion, hobbies, etc.)
Strengths and skills
Client self-ratings:
On a scale of 1 to 10, client rates his/her current functioning at _____.
Areas the client feels are impaired/impacted by the concern/problem(s):
What stage of change does client appear to be at?
□ Pre-contemplation
□ Contemplation
□ Planning
□ Action
□ Maintenance
What does the client think would help move him/her towards the next level?
Are there any barriers to change/reasons for maintaining the problem(s)?
How will he/she know that things are getting better?
Initial goals and plan:
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VII. Behavioral Observations (check boxes and note any specific observations below each)
Appearance:
□ Normal
Eye contact:
□ Good
□ Tidy
□ Disheveled
□ Culturally appropriate
□ Immature
□ Unclean
□ Adequate
□ Unusual
□ Inconsistent
□ Overly intense □ Poor
Gait/Gross Motor Movement: □ Normal
□ Accelerated □ Slowed/retarded
□ Clumsy/lacking coordination □ Exaggerated □ Peculiar
Posture:
□ Normal
Mannerisms:
□ None noted □ Tics
□ Rocking
□ Grimacing
□ Flapping
□ Tremors
□ Other
Energy Level:
□ Normal
Speech:
□ Normal
□ Quiet □ Slowed
□ Slumped
□ Rigid
□ Stiff/Rigid
□ Atypical
□ Fidgety
□ Lethargic
□ Nonverbal
□ Monotone
□ Halting/difficulty finding words □ Rapid
□ Loud
□ Impoverished
□ Peculiar topics/other □ Stuttering
□ Tearful/sad
□ Anxious
□ Fluctuating
□ Tugging
□ Hyperactive
Patterns of Behavior: □ Unremarkable □ Rituals
Affect: □ Composed
□ Apathetic
□ Dramatic
□ Dysmorphic
□ Agitated/restless
□ Stereotypy (unvarying repetition) □ Compulsions
□ Distressed
□ Blunt/flat
□ Euphoric
□ Suspicious
□ Labile
□ Angry
□ Shallow
□ Inconsistent with thought/speech
VIII. Cognitive Observations (check boxes and note any specific observations below each)
Consciousness:
□ Alert
□ Drowsy/dazed □ Easily startled
□ Unresponsive
□ Under-responsive
Attention:
□ Good
□ Distractible
Orientation:
□ Normal
Impaired orientation to: □ Person
Memory:
□ Intact
□ Impaired STM
□ Selective
□ Impaired LTM
□ Obsessions
□ Inadequate
□ Place
□ Confused
□ Pre-occupied
□ Time
□ Situation
□ Impaired immed. Recall □ Adeq. recall w/effort
Intellectual Functioning: □ Average
□ Below Average
Any known deficits:
□ Verbal
□ Non-verbal
Thought Content: □ Unremarkable
□ Fluctuating
□ Above Average
□ Pre-occupation
□ Delusions
Thought Process: □ Unremarkable
□ Non-linear
□ Delusions
□ Loose associations □ Paranoia
□ Rapid shifts of focus □ Narcissism □ Somatic pre-occupations □ Obsession □ Grandiosity
□ Other (specify)
Perceptual Disturbance:
□ None
□ Flashbacks □ Dissociation
Hallucinations: □ Visual □ Auditory □ Tactile □ Olfactory
Insight:
□ Developmentally appropriate □ Denies Problem
Judgment:
□ Dev. appropriate
□ Unsafe behavior
□ Poor decision-making
□ Projects blame
□ Inflexible
□ Poor
□ Easily overwhelmed
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IX. Diagnostic Impressions
Preliminary diagnosis:
Therapist signature: _________________________________________________ Date: _____________
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