Maryasha Katz, LCSW

 Therapy Office of Maryasha Katz, LCSW

(831) 234-5813

Self-Assessment

To save time, you may print this, fill it out and bring to your first appointment.  Otherwise, I will invite you to fill it out at your first appointment.  If you have difficulty with reading/writing, or for any other reason,  we can fill this out together if you prefer.

Name______________________________  Date_________________________

Date of Birth______________________                        Age_________

Address_________________________________________________________

 _______________________________________________________________

Telephone Numbers________________________________________________

OK to leave a message?  Yes     No

Occupation_______________________________________________________

How did you hear about my services?__________________________________

With whom are you now living?  (list people)_____________________________

Where do you reside?  __house  __hotel  __room  __apartment  __other

Significant relationship status:

__single  __engaged  __married  __domestic partners  __separated  __divorced

__remarried  __committed relationship  __widowed  __other

If intimately involved with another person(s), what is that person’s name, age, occupation?

Satisfaction with relationship?

What is happening in your life that has resulted in this appointment?

What would you like to see accomplished in therapy?

Chief Complaint (Check all that apply to you):

__Use of drugs and/or alcohol  (If yes, how much are you using?)

__Use of prescription medications (If yes, which ones and how much are you using?)

__Blackouts

__Physical abuse issues

__Sexual abuse issues

__Child sexual abuse issues

__Emotional abuse issues

__Domestic/partner violence

__Other problems/symptoms:

Previous outpatient therapy?              Yes             No

If yes, with whom?_________________________________________________

How did you feel about your experience and what was accomplished?

Previous hospitalizations?              Yes            No            Number of hospitalizations_____

If yes, when_______________________________________________________

What are some things that you feel like you are good at or are your strengths?

Please indicate if there is anything else you would like me to know:

Thank you for taking the time to fill this out.

Last revised 9/12