Generic Mental Health Assessment



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Generic Mental Health Assessment Form

Personal History




Education:
School years?

Trusting?

Friends?


Bullying?

Qualifications?


Childhood:
Where born?
Any complications in birth?
Developmental stages?

Home atmosphere?


Relationship with parents?



Employment:
Current jobs?

Previous jobs?

How many?

Reasons for leaving?


Spiritual beliefs:
Brought up with religion?


Currently practice?





Sexual history:
Any difficulties during puberty?


Any distressing sexual experiences?

Sexually active?


Any problems?

Relationships:
Family dynamics

Past serious relationships

Social network


Plans?


Substance Use (identify if the following are used as coping mechanisms for the issue in question)

Alcohol: What sort? How much? What strength? What time of day? Why do you use it? Does it help with your symptoms? Any intention to reduce or stop?

Illegal Drugs: What sort? How much? What strength? What time of day? Why do you use it? Does it help with your symptoms? Any intention to reduce or stop?

Prescribed Medication: What sort? How much? What strength? What time of day? Why do you use it? Does it help with your symptoms? Any intention to reduce or stop?
Non-prescribed Medication: What sort? How much? What strength? What time of day? Why do you use it? Does it help with your symptoms? Any intention to reduce or stop?

Tobacco: How much? What strength? What time of day? Why do you use it? Does it help with your symptoms? Any intention to reduce or stop?


Caffeine: How much? What time of day? Why do you use it? Does it help with your symptoms? Any intention to



reduce or stop?



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