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Psychological Assessments and Evaluations at VCAT Treatment Center

Psychological Assessment at VCAT Treatment Center

Date

Month

Day

Year

Section 1: Personal Information

First name

Last name

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!

Other Websites:

www.vcattreatmentcenter.com

www.vcatadhdtreatment.com

VCAT Psychological Testing Center

3151 Airway Ave Suite C3

Costa Mesa, CA.92626

info@vcattreatmentcenter.com

Office:(714)714-0532

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