Adolescent Mental Health Assessment Form
Personal Information
Full Name
Date of Birth
Age
Gender
Male
Female
Other
School/Institution
Grade/Class
Mental Health History
Presenting Concerns
History of Mental Health Issues
Family History of Mental Health
Current Medications
Psychosocial Assessment
Academic Performance
Peer Relationships
Family Relationships
Sleep Patterns
Substance Use
Symptoms Checklist
Sadness/Low mood
Anxiety/Nervousness
Irritability/Anger
Social Withdrawal
Poor Concentration
Appetite/Sleep Disturbances
Thoughts of Self-Harm
Other
Clinician Notes
Clinical Observations
Assessment Summary
Recommendations / Next Steps