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CRT COUNSELING-Change, Renewal, Transition, PA

Printable - CLINICAL ASSESSMENT form

 


first naME______________________________
last name_______________________________

month _____________ day___________ year__________

PRESENTING PROBLEM AS STATED BY CLIENT

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hISTORY OF PRESENTING PROBLEM (ONSET OF PROBLEMS, SYMPTOMS, BEHAVIORS, INCLUDING PSYCHOLOGICAL AND SOCIAL STRESSORS):

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.

FAMILY HISTORY OF SUBSTANCE ABUSE AND MENTAL HEALTH:

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PAST AND PRESENT USE OF CIGARETTES, ALCOHOL/DRUGS (INCLUDE OVER THE COUNTER):

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DEVELOPMENTAL HISTORY (PRENATAL AND PERINATAL EVENT FOR CHILDREN AND ADOLESCENTS):

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PAST MEDICAL HISTORY
(INCLUDING HOSPITALIZATIONS, SURGERIES. MAJOR ILLNESS, AND MEDICATIONS):

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CLIENT'S:
STRENGTHS

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WEAKNESSES

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MEDICATIONS       (NOTE FREQUENCY,DURATION,PURPOSE,EFFECTIVENESS & MD WHO PRESCRIBED):

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