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Psychotherapy Assessment Questionaire

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9 views1 page

Psychotherapy Assessment Questionaire

Uploaded by

christophernkwenti
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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PSYCHOTHERAPY ASSESSMENT QUESTIONAIRE

PERSONAL DATA

Dat
___________________________________________ __________________________________
Name e
DO Ag
________________________________________ ______________ ____________
B e
Address ________________________________________ Sex Male Female
Telephon
________________________________________ _____________________________
e
Occupati No. of
_______________________ Marital Status _________ ____________
on children(s)
Spouse/Partner’s
____________________________________
Occupation
Person to contact in an
________________________________ Telephone ________________
Emergency
Address __________________________________ Relation to you ____________________________

MAIN PROBLEMS

Please list the major problems that you would like help with in therapy, and rate the severity of each one according to the
scale below:
1--------- 2--------- 3--------- 4--------- 5--------- 6--------- 7--------- 8--------- 9--------- 10
Not a problem Mild Problem Moderate problem Severe Problem Couldn’t be worse RATING
1. _______________________________________________________________________________________ _________
2.________________________________________________________________________________________ _________
3.________________________________________________________________________________________ _________
4.________________________________________________________________________________________ _________
Briefly describe what motivated you to seek therapy at this time (rather than some time earlier or later):
_____________________________________________________________________________________________
________________________________________________________________________________________

2024 MacMillan Wellness Center Ltd Fax: 677625620


P.O. Box: 612, Bamenda Tel: 677625621

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