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At
VCAT Treatment Center Costa Mesa Orange County
Psychological Assess and Evaluations
Psychological Assessment at VCAT Treatment Center
Intake Form
Date
Month
Day
Year
Section 1: Personal Information
First name
Last name
Email
Phone
Date of Birth and Age
Gender Identity:
Male
Female
Ethnicity:
Education Level: High School, College, Graduate, Other: Describe
Referral Source: Self, Physician, School, Family, Other: Describe
Section 2: Presenting Concerns
Reason for Assessment: Describe in details!
Duration of Symptoms:
<1 month
1–6 months
6–12 months
>1 year
Duration of Symptoms:
<1 month
1–6 months
6–12 months
>1 year
Severity:
Mild
Moderate
Severe
Areas Affected:
Mood
Anxiety
Attention
Memory
Sleep
Relationships
Work/School
Trauma
Substance Use
Other
Section 3: Mental Health & Medical History
Previous Diagnoses: Describe
Psychiatric Hospitalizations: None , Yes → Dates:
Medications: None, Yes → List:
Therapy History: None, Yes → Type:
Family History of Mental Illness:
Check all Related
Depression
Anxiety
Bipolar
Schizophrenia
Substance Use
Trauma
Other
Section 4: Functioning & Stressors
Relationship Status: Single, Married, Divorced, Partnered , Other: Describe!
Work/School Performance: Excellent, Adequate, Poor
Major Stressors: Financial, Health, Family, Work, Trauma, Legal, Other: Describe!
Submit
Complete your intake form to begin your psychological evaluation. All infor
mation is confidential
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