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302 E Manchester Blvd #203
Inglewood, CA, 90301
424-241-0164
Inglewood, CA
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Home
Services
The Team
The Space
Client Sign Up
Media
Staff Portal
Assessment
Please complete the form below within 7 days of the initial session.
Date of Initial Meeting
*
MM
DD
YYYY
Name of Therapist
*
First Name
Last Name
Initials of Client
*
Gender
*
Male
Female
Non-binary
Other
Age of Client
*
Partnership Status
*
Married
Unmarried
Single
Divorced
Entangled
Domestic Partnership
Other
PRECIPITATING EVENTS(S)/REASON FOR REFERRAL CURRENT SYMPTOMS AND BEHAVIORS (INTENSITY, DURATION, ONSET, FREQUENCY) and IMPAIRMENTS IN LIFE FUNCTIONING
*
Suicidality
*
Yes
No
Passive
History of Suicidality
*
History of Mental Health Services
*
History of Homicidality/Thoughts
*
Trauma History
*
History of Psychotropic Medication
*
Use, Frequency & History of Substances
*
Medical History
*
Educational History
*
Employment History
*
Legal History
*
Current Living Arrangement
*
Caretaker of dependent children or adults?
*
Family History/Relationships
*
Mental Status Exam
*
Please describe Client's presentation/affect/mood/thought process, etc.
Client's Strengths
*
Clinical Formulation
Date of Submission of Assessment
*
MM
DD
YYYY
Thank you!
