Psychological Assessment Form

A psychological assessment form is a document which has to be filled in by an individual who believes that he may require counseling, psychological treatment or medical help of this sort. It is available in the offices of most psychologists and is used as the primary indication of the individual’s mental conditions. They are usually filled in by the potential patient himself and must be accurate. All efforts should be made to provide a well framed form which can extract the relevant information from the candidates.

Sample Psychological Assessment Form

Please fill in the following psychological assessment form according to the key provided below:

1: Repeatedly 2: Frequently 3: Occasionally 4: Rarely

  • Panic attacks, sweating of palms, nausea and palpitation: ____________________
  • Feelings of extreme nervousness and fear among people or in a crowded place: _______
  • Persistent phobias, feelings of paranoia: _________________________
  • Physical manifestations that are not responding to treatment [gastric ulcers, weight loss or gain, loss of appetite]: ___________________________
  • Chronic depression, suicidal urges, feelings of loneliness and victimhood: ____________
  • Physical tics like chewing of fingernails, constant fidgeting, movements that are regularly repeated over a period of time: ______________________________

Please answer the following questions clearly

  • Do you have a history of drug abuse? Do you smoke or drink on a regular basis? ____________________________________________________________
  • Do you have a history of nerve related disorders? Have you ever sought counseling/psychological treatment before? _______________________________________________________________
  • Why do you feel that you need psychological help? ________________________________________________________________
  • How often do you submit yourself to medical checkups? _________________________________________________________

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