Outpatient Assessment - Adult

Client Assessment Form

This Assessment form is to help our Clinicians better understand your situations . It is important to understand that this information is electronically delivered to a certified Clinician, and will not be shared with anyone without your prior consent. You will be contacted soon after completing this assessment to discuss Better Living Counseling Services outpatient therapy option.

Client Information
Client's contact phone number *
Client's contact phone number
Other Party Completion
If the client is not the individual completing this form, then this section is for the individual concerned enough to request assistance. These fields are optional.
Informants Name
Informants Name
Informants Contact Phone Number
Informants Contact Phone Number
Assessment
The questions below ask about things that might have bothered you. For each question, select the option that best describes how much (or how often) you have been bothered by each problem during the past TWO (2) WEEKS.

Assessment derived from DSM-5 Cross-Cutting Symptoms Measure.  Copyright ©2013 American Psychiatric Association. Material reproduced with permission