PhoenixWay Self-Assessment

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Mental Health Self-Assessment

(Please note that all information submitted here is private, confidential, and protected by law.)

Demographic Information

* Indicates required field

Full Name *

Email *

Date of Birth *

Address (Number & Street) *

Address (City, State, Zip) *

How did you discover PhoenixWay? *

Name of Insurance Company (or Private Pay) *

Insurance ID# (N/A for Private Pay) *

County of Residence *

Phone (Mobile Preferred) *

Gender *

Female Male

Emergency Contact *

Relationship *

Phone *

Currently Under Physician's Care? *

Yes No

Name of Practice / MD or NP *

Location of Practice *

General Health/Medical Information

Are you pregnant? *

If so, how many weeks? *

Receiving prenatal care? *

Yes No

Name of OB/GYN *

Ever Been Diagnosed With? *

Hepatitis B/C/D HIV Tuberculosis (TB) Diabetes Serious Head Injury / TBI None of the Above

Please give dates for any of these diagnoses *

Do you use tobacco? *

Yes No

Interested in stopping? *

Yes No N/A

Have you gained/lost a lot of weight recently? *

Gained Lost N/A

How much gained or lost and how recently? *

Social History (Family & Natural Supports)

Relationship Status *

How many children do you have? *

Current Housing Situation *

Does anyone live with you? *

Yes No

List relationship & age *

Anyone in your immediate BIOLOGICAL family with mental health or substance use problems? *

Mother Father Paternal GM Paternal GF Maternal GM Maternal GF Aunts or Uncles Brothers or Sisters None of the Above

Please give details for any checked boxes *

Spirituality or Religion? *

If Other, please describe: *

Do you attend? *

Please check any of the following that apply: *

Family conflict Separation or recent divorce Grieving death of loved one/close friend Difficulty making/keeping friends Lonely/isolated Experienced physical abuse Experienced sexual abuse Experienced emotional abuse Other Family/Social Problems None of the Above

Please give whatever details you are willing to share: *

Educational, Employment, Military History

Highest Grade Completed *

Currently enrolled in school? *

Yes No

If so, where? *

Currently working? *

Yes No

Type of work / Position *

Employer *

Current work status *

If not working, would you like to work? *

Yes No

If so, doing what? *

Have you or immediate family member served in the military? *

Yes No

If yes, please give details (branch, active/inactive, which family member/s) *

Legal History

Have you ever been arrested? *

Yes No

If so, please give number of arrests: *

Most recent arrest date? *

Currently scheduled for court? *

Yes No

Currently on probation? *

Yes No

Spent time in jail/prison? *

Yes No

If so, how long? *

Under legal pressure to attend therapy? *

Yes No

Please give arrest dates, charges, and whether convicted *

Please check if any of these are going on for you:

Please choose from list: *

Adjustment issues Anxiety/Worry/Stress Depression/Sadness Mania Obsessions/Compulsions Hallucinations/Delusions Paranoia Self-Harm (non-suicidal) Danger to self (suicidal thoughts/actions) Danger to others (homicidal thoughts/actions) None of the Above

Please choose from list: *

Work issues or lack of stable employment Academic/school issues Financial problems Attention/focus problems Social skills problems Self-care issues Anger control issues Aggression/violence Perpetrator of physical abuse Perpetrator of sexual abuse Perpetrator of emotional abuse None of the Above

Please choose from list: *

Eating disorder/food issues Substance use--alcohol Substance use--other drugs Prescription drug overuse Sleep disturbance/problems Recent hospital discharge Multiple hospitalizations--psychiatric Multiple hospitalizations--medical Medical/physical health problems Medication allergies Other not stated None of the Above

Please feel free to add any more detail here: *

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