Adult Evaluation Form - Sophia Robinson, Psy.D.
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Adult Evaluation Form

Name: (required)

Gender:
MaleFemale

Date:

Date of Birth:

Birthplace:

Age:

Address:

City, State, Zip:

Home Phone:

Cell Phone:

Work Phone:

May Dr. Robinson leave personal voice messages on one of your phones?
YesNo

If yes, which phone(s):
HomeCellWork

Do you consent to receiving text messages from Dr. Robinson?

YesNo

Do you consent to receiving emails from Dr. Robinson? YesNo
Email:

Health Plan Information:

Primary Plan:

Policy/Subscriber #:

Subscriber's Name:

D.O.B:

Soc. Sec. #:

Plan Ph#:

Claim Address:

Secondary Plan:

Policy/Subscriber #:

Subscriber's Name:

D.O.B:

Soc. Sec. #:

Plan Ph#:

Claim Address:

Emergency Contact Information:

Name:

Relationship:

Phone:

Referral Source:

Presenting Problems (be as specific as you can: describe problems, when did it start,...):
1.
2.
3.

Estimate the severity of above problem:
#1 MildModerateSevereVery Severe
#2 MildModerateSevereVery Severe
#3 MildModerateSevereVery Severe

School History:

Currently in School? YesNo

Highest Grade / Degree:

Last/Current School Attended:

Average Grade Received:

Learning Strengths:

Specific Learning Disabilities:

Any behavioral problems in school?

What have teachers said about you?

Did you like school? YesNo

Comment:

Employment History:

Patient's Occupation:

Current Employer: (former. if no longer working):

Favorite Job(s):

Least Favorite Job(s):

Any work-related problems?

What would employers say about you?

Relationship and Family History:

Current Marital Status:
SingleMarriedSeparatedDivorcedWidowedLiving together

Name of Spouse/Long term partner:

Length of Current Relationship:

Spouse/Partner Occupation:

Describe any stressors in current relationship:

List Past Marriages (start and end date, years together, names & statement about the nature of the relationship/s):
1.
2.
3.

Children/Step Children (names/ages & brief statement on your relationship with the child/adult):
1.
2.
3.
4.

Siblings (name/age, if deceased: age and cause of death & brief statement about the relationship):
1.
2.
3.
4.

Biological Mother's History:

Living

Age

Deceased

Age

Cause of Death

If living, describe current relationship with her

Medical Problems:

Psychiatric Treatment:

Mother's drug / alcohol history:

Have any of your mother's blood relatives had any significant medical or psychiatric problems including drug or alcohol abuse/addiction, depression, anxiety, psychiatric hospitalization, suicide attempts?

Biological Father's History:

Living

Age

Deceased

Age

Cause of Death

If living, describe current relationship with her

Medical Problems:

Psychiatric Treatment:

Father's drug / alcohol history:

Have any of your father's blood relatives had any significant medical or psychiatric problems including drug or alcohol abuse/addiction, depression, anxiety, psychiatric hospitalization, suicide attempts?

Describe your childhood (Relationships with parents, siblings, others, school, neighborhood, relocations, any school/behavioral/problems):

If Parents Divorced, Your Age at the Time:

How did their divorce affect you?

Medical History:

Primary Care Doctor (name /phone/city):

Other Medical Specialists (name/phone/condition they are treating):
1.
2.
3.

Past and Present Medical Care (major medical problems, surgeries, injuries, illness):

Current Medications (Name, Dosage, Issue for which each medication is prescribed):
1.
2.
3.
4.
5.

Past / Present Psychotherapy / Neurofeedback History (start-end date, approx. # of sessions,
helpfulness, name, city, ph# of therapist, reason treatment ended):

Psychiatric Hospitalizations (specify: month, year, number of days of each hospitalization, name of
hospital, reason for hospital):
1.
2.
3.

Alcohol and Drug History:

Do you ever experience withdrawal symptoms from alcohol or drugs?
YesNo

Describe:

Has anyone ever told you they think you have a problem with alcohol or drugs?
YesNo

Please Explain:

Have you ever felt guilty about your alcohol or drug use?
YesNo

Have you ever felt annoyed when someone spoke to you about your alcohol or drug use?
YesNo

Have you ever used alcohol or drugs first thing in the morning?
YesNo

Have you ever tried to cut down on your drug/alcohol use and been unable to do so?
YesNo

Have you been through any programs to treat substance abuse or addiction?
YesNo

Please list programs:
1.
2.
3.
4.

C=Current    Use P=Past    Use Please describe use on line provided.

Alcohol
CP

Nicotine
CP

Marijuana
CP

Cocaine / Methamphetamine
CP

Opiates
CP

Hallucinogens
CP

Prescription sleeping pills or tranquilizers
CP

Steroids
CP

Other
CP

Sleep Behavior: (describe any yes answers):

Any problems falling asleep?
YesNo

Any problems staying asleep?
YesNo

Any problems waking up?
YesNo

On average, how many hours do you sleep at night?
YesNo

History of sleep apnea
YesNo

Do you snore
YesNo

Do you or have you had sleep walking
YesNo

Do you have frequent nightmares
YesNo

Do you grind teeth during sleep
YesNo

Diet and Exercise History:

Would you consider your diet mostly healthy or unhealthy?

Any food allergies or sensitivities?

Are you on a restricted diet?
YesNo

Describe:

Caffeine consumption per day (chocolate, coffee, tea, 󠆸soda...):

Sugar consumption per day:

Describe your current bowel function:
NormalConstipatedLooseDiarrhea

Describe your current exercise routine:

Do you consider yourself to be over or under weight?
UnderweightOverweightNeither

What is your ideal weight?

How long have you struggled with your weight issues?

What weight loss measures have you tried?

Cultural and Ethnic Background:

Describe Yourself

Describe Your Strengths

Describe Your Weaknesses

Describe Your Friendships

Interested in Christian Counseling?
YesNoMaybe, please tell me more about it

Please use this space to let me know anything else about yourself that you would like me to know: