Certified EMDR Therapist | Psychosocial Assessment

Psychosocial Assessment

First of all, thank you for taking the time to fill this form.

Once you complete this form by clicking the Submit button below, you and I will receive an email copy of your filled form. It may take a few minutes for this email to arrive and please check your spam folder if you don’t receive it after a while. If you have any questions regarding this form, please feel free to email me.

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Form filling tips:

This online form needs to be completed within one seating as it will not save any information online to go back to. If you need more time to fill it, please print and fill it offline by accessing this link.

For any required fields that are not applicable to you, please type in NA (Not Applicable) to avoid any submission error.

Thank you and respectfully,

Robert

DEMOGRAPHIC INFORMATION - Client Legal Name: *

Name that you would like to be called: *

Email: *

Address: *

DOB (mm/dd/yyyy): *

Confidential Phone: *

Employer: *

INSURANCE INFORMATION - Name of insurance plan: *

Subscriber id: *

CO PAY: *

Deductible: *

Name of Employer (of your insurance plan): *

Phone numbers on the back of your insurance card: *

Name of primary insurance holder and DOB if different from your own: *

Type NA if not applicable

Married, Partnered, Single? *

Name of partner if you have one: *

Type NA if not applicable

Names of children if you have them: *

Type NA if not applicable

Emergency contact person and phone (see note below): *

Please note: I do everything to meet the confidentiality best practices of this profession. However, if you are a no show or I cannot reach you and have not been notified of your absence in advance, I may need to reach out to your confidential emergency contact.

PRESENTING ISSUE(S) bringing you to therapy: *

FAMILY INFORMATION - Name of parent(s): *

Occupation of parent(s): *

Location of parent(s): *

Describe general relationship with your parents - Describe relationship to them as a child? *

Describe relationship to them now? *

Siblings - Names and ages of siblings if any. *

Type NA if not applicable

Relationship now with your siblings: *

PREVIOUS MENTAL HEALTH HISTORY - Name and location of previous therapist. *

Type NA if not applicable

Reason for therapy at that time: *

Type NA if not applicable

How long were you in therapy? *

Type NA if not applicable

Why were you in therapy? *

Type NA if not applicable

Was therapy helpful? *

Type NA if not applicable

Name, location, and phone of your CURRENT Psychiatrist: *

Type NA if not applicable

CURRENT PSYCHOTROPIC Medication. Please list name and dosage. *

Type NA if not applicable

DIAGNOSIS - When, date and year were you first diagnosed? *

Type NA if not applicable

Explain treatment for that diagnosis: *

Type NA if not applicable

Select all that apply: *

List phobias, if any: *

Type NA if not applicable

Do you have “night terrors” or bad dreams? If so, how often? Please describe a dream or 2 if you remember. *

Type NA if not applicable.

CHILDHOOD HISTORY - Describe your childhood? Did you feel safe, loved, cared for, protected, nurtured? Please elaborate. *

Childhood Traumas - History of accidents. Did anyone abuse you verbally or sexually? *

History of hospitalizations: *

Diseases as a child: *

Did your parents play with you? *

Did you have friends? Explain your social skills/ability. *

Were you bullied at any point in your childhood? *

Did you play sports? If so, what kind of sport did you engage in? *

How would you summarize your childhood? In a few sentences if you can. *

ADULT HISTORY - Your education, high school, college. *

EMPLOYMENT - Were you regularly employed? Were you ever fired from a job? *

TWENTIES - Describe your 20’s. If you are still in your 20’s, how are they going so far? Try to be descriptive. *

THIRTIES (please describe) *

Type NA if not applicable

FORTIES (please describe) *

Type NA if not applicable

FIFTIES (please describe) *

Type NA if not applicable

SIXTIES (please describe) *

Type NA if not applicable

SUBSTANCE USE - History (Please list any substances you experimented with or may have had an issue with. Please include your age and current substance use activities. Also, please let me know if you have a current substance use issue so that I can help you with that.) *

Are you in any type of SA treatment? *

Type NA if not applicable

Have you ever been in SA treatment? Please provide details. *

Type NA if not applicable

Any childhood issues with substances? *

Parents or caregiver issues with substances? *

FINANCIAL HISTORY - Any financial issues, previously or now? *

Did you learn about finances as a child or young adult? If so, how? *

Legal Issues - Please explain any past or current legal issues: *

MEDICAL HISTORY - Name of your current PCP or GP: *

Location and phone number of current PCP or GP: *

Any current medical problems? *

Hospitalizations? List date and circumstances. *

Surgeries? Please list name of surgery and dates. *

Type NA if not applicable

Are you on any MEDICAL medication I should know about? *

Overall Health is (please select one): *

Excellent
Good
Fair
Poor

Explain your eating habits: *

Explain your exercise regimen: *

Explain your sleep patterns: *

TRAUMA HISTORY - Sometimes people are unsure if they have experienced something traumatic. Please take a moment and scan your life to date. Does an event come up that feels emotionally “charged”? *

Can you think of a time or event that feels unresolved emotionally? *

Do you ever space out to a point that it interferes with your daily life? *

Please list any issues that you think may have been a “trauma” or feels unresolved or emotionally charged: *

SEX HISTORY (please elaborate if you feel comfortable) - How do you identify sexually ex: Hetero, cis-gender, trans, LGTBTQQi, queer, lesbian, etc.

Please explain your first experience with sex:

Do you have any issue with your sexuality?

Do you have any physical issue that prevents you from having sex?

Do you enjoy sex?

CURRENT SUPPORT SYSTEM - Please describe you current support system (friends/family/partner etc). *

Do you have a large, medium or small group of friends? *

Are you social? *

Do you have any issues in crowds? *

Do you like meeting new people? *

Who is your primary support person? *

Biggest Adult Life challenge has been? *

THERAPY NOW - Explain in detail why you are seeking therapy. *

WHY NOW? *

Explain what you hope to achieve from therapy and list a few goals. *

How long are you willing to commit to the process of therapy? *

PLEASE EXPLAINS YOUR STRENGTHS and things that you like about yourself. *

EMDR - Are you seeking EMDR treatment? *

Have you had EMDR before? Please explain when, what for and with whom. *

Please explain in a few words why you are seeking EMDR now (we will discuss this in detail upon our first session). *

FINALLY Please write any information that you think it would be important for me to know about you! This will be helpful for the process of therapy. *

Today's Date: *

Thank you for taking the time to do this! - Robert Norgaard, LMFT

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