Mental Health Client Assessment Form
Personal Information
Full Name
Date of Birth
Gender
Male
Female
Non-binary
Other
Prefer not to say
Address
Phone
Email
Emergency Contact
Name
Relationship
Phone
Presenting Concerns
Please describe your main concerns
Mental Health History
Any previous mental health diagnoses?
Are you currently taking any medication?
Any history of psychiatric hospitalization?
Substance Use
Describe any substance use (alcohol, drugs, etc.)
Family and Social History
Is there a family history of mental health issues?
Describe current living situation
Social support available
Risk Assessment
Any thoughts of self-harm or suicide?
Any thoughts of harming others?
Additional Notes
Other information