Adolescent Mental Health Assessment Form
Full Name
Date of Birth
Age
Gender
Female
Male
Non-binary
Other
Prefer not to say
School/Institution
Grade/Year
Referral Reason
Relevant History (medical, psychiatric, family)
Current Concerns/Symptoms
Strengths & Interests
Current Support System (family, friends, community)
Risk Assessment (self-harm, suicidality, violence, abuse)
Additional Notes