CALL NOW 602-478-1477
(F) 602-773-0998
RISA E. NEWELL, Ph.D., L.L.C.
LICENSED CLINICAL PSYCHOLOGIST
Patient Evaluation - VIEWING INPUT
Risa Newell, Ph.D., L.L.C., Licensed Clinical Psychologist
7047 E. Greenway Parkway, #250 | Scottsdale, AZ 85254
(T) 602-478-1477 (F) 602-773-0998 risa@newellphd.com
Newellphd.com
Thank you for taking the time to complete this evaluation – a thorough review of important parts of your life. The following questions are personal and sensitive in nature and will remain strictly confidential and secure. By completing this form, you will provide valuable information for the therapeutic process and expedite our important work ahead.
You may also just bring this form with you to your Initial Evaluation appointment.
Identifying Information
* Required
Elizabeth M Nachman
03 27 1981
Partner/Spouse, Children
Married
Brandon Nachman
05 25 1977
LeRay Female 15, Benjamin Male 11
Howdy- golden retriever
best friend Mary Louis lives in Alabama
true
RN
Mayo Clinic
Brandon Nachman
4806944554
husband
End of Identifying Information section
Current Concerns
What are you most concerned about now?
Managing anxiety. I want my body and mind to be able to relax and enjoy my family. I have ADHD and managed it as a child from age of 9-14 on Ritalin and then discontinued it because my grades improved as well as my focus and I have not been on any medication since. I have had a series of traumatic events in my adulthood and I think i am trying to figure out how to manage ADHD, Perimenopause and anxiety and which one or if all are the culprit. I just stated zoloft Sunday 3/22 (half dose 12.5) will transition to 25 next week.
Please rate your current level of distress, from 1-10, (1=minimal to 10=extreme):
7
When do you tend to feel the worst?
Please indicate how long you’ve been feeling this way now:
Since 2022 aftermath of COVID
Have you ever felt this way in the past?
Yes
If so, when and how severe?
I thought anxiety was new to me as an adult but looking back into childhood I have always had it.
What has been done so far to address these concerns?
journal , exercise, postive self talk
Do you have any negative beliefs about yourself?
Yes
If yes, what are they?
Wish i was more organized and a better planner.
Specify which areas of your life are affected by this problem:
Physical, Relationships
Other?
End of Current Concerns section
Stressful Life Events
Please indicate if any of the following have occurred within the past 12 months:
Other:
End of Stressful Life Events section
Psychiatric Symptoms: DSM-5 Self-Rated Measures - Adult
Instructions: The questions below ask about things that might have bothered you. For each question, select the frequency that best describes how much (or how often) you have been bothered by each problem during the past TWO (2) WEEKS.
During the past TWO (2) WEEKS, how much (or how often) have you been bothered by the following problems?
None
Not at all
Slight
Rare, less than a day or two
Mild
Several Days
Moderate
More than half the days
Severe
Nearly every day
1. Little interest or pleasure in doing things?
0 None - Not at all
2. Feeling down, depressed, or hopeless?
1 Slight - Rare
3. Feeling more irritated, grouchy, or more angry than usual?
3 Moderate - More than half the days
4. Sleeping less than usual, but still have a lot of energy?
3 Moderate - More than half the days
5. Starting lots more projects than usual or doing more risky things than usual?
0 None - Not at all
6. Feeling nervous, anxious, frightened, worried, or on edge?
4 Severe - Nearly every day
7. Feeling panic or being frightened?
1 Slight - Rare
8. Avoiding situations that make you anxious?
1 Slight - Rare
9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs?)
0 None - Not at all
10. Feeling that your illnesses are not being taken seriously enough?
2 Mild - Several Days
11. Thoughts of actually hurting yourself?
0 None - Not at all
12. Hearing things other people couldn't hear, such as voices even when no one was around?
0 None - Not at all
13. Feeling that someone could hear your thoughts, or that you could hear what another person was thinking?
0 None - Not at all
14. Problems with sleep that affected your sleep quality overall?
2 Mild - Several Days
15. Problems with memory (e.g., learning new information) or with location (e.g., finding your way home?
0 None - Not at all
16. Unpleasant thoughts, urges, or images that repeatedly enter your mind?
0 None - Not at all
17. Feeling driven to perform certain behaviors or mental acts over and over again?
0 None - Not at all
18. Feeling detached or distant from yourself, your body, your physical surroundings, or your memories?
0 None - Not at all
19. Not knowing who you really are or what you want out of life?
0 None - Not at all
20. Not feeling close to other people or enjoying your relationship with them?
0 None - Not at all
21. Drinking at least 4 drinks of any kind of alcohol in a single day?
0 None - Not at all
22. Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco?
0 None - Not at all
23. Using any of the following medicines ON YOUR OWN, that is, without a doctor's prescription, in greater amounts or longer than prescribed [e.g., painkillers (like Vicodin), stimulants (like Ritalin or Adderall), sedatives or tranquilizers (like sleeping pills or Valium), or drugs like marijuana, cocaine or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)]?
0 None - Not at all
End of DSM-5 Symptoms
Current Status
B.S. Nursing and History
Are you currently attending school?
Nursing
18 years
Medium
Have you ever been terminated from a job?
No
High
Are you currently receiving disability?
No
No
Are you an active member of the Armed Forces?
No
Have you ever served in the military?
No
Were you ever in combat?
Partner, Friends, Neighbors
Are you satisfied with your home and family life?
Yes
Somewhat
How socially active are you?
Who do you most enjoy spending time with?
Husband and kids
How important is religion and/or spirituality in your life?
Very / Somewhat / Not at all
Very
Are you physically active? Yes / Sometimes / No
Current satisfaction with lifestyle, hobbies, activities:
High / Medium / Low
Yes
Medium
Please list your favorite activities, interests or hobbies:
I use to hike and bike alot but now feel stretched for time
Briefly describe how you spend a typical day:
I work 3 - 12 hour shifts a week in a hospital. Days off exercise, catch up on house work, walk with a friend, run kids to sports after school.
What do you like most about yourself?
I have a big heart and am empathetic to those with struggles
Please describe one of your favorite memories:
Fishing in northern California with my family on vacation and my children's fishing lines caught one another under the boat and they were both pulling thinking they caught a fish.
End of Current Status section
Current Relationships
Husband
Are you currently in a committed romantic relationship?
Yes
If YES, with whom and for how long?
Been together 22 years, married 18
Quality of relationship: (Positive / Mixed / Negative)
Positive
Any current romantic relationship conflicts?
No
Are you concerned about any potential violence?
No
Any recent breakups?
No
If you have children, are there any current relationship difficulties?
No
If you are co-parenting with an ex-partner, any areas of concern or conflict?
No
Any relationship problems with other family members, (parents, siblings, etc.)?
Yes
Any conflict with others outside of family, (friends, coworkers, neighbors, etc.)?
No
End of Current Relationships section
To whom are you closest?
Mental Health Treatment History
Age at first mental health treatment:
24
Why did you seek/receive treatment?
After my parents car accident for grief support, My mother died, father survived accident
Have you ever met with a therapist?
Yes
Grief/Anxiety
Beth Keen
If you would like me to consult with your previous therapist, please designate and sign your consent below:
March 25, 2026 at 5:09:28 PM
Have you ever been hospitalized for a mental health condition?
No
If yes, please complete below:
Have you taken psychiatric medication in the past?
No
If yes, please complete below:
End of Mental Health Treatment History section
Providers
Primary Care Physician
Dr. Shihab
4803420000
Consent to contact
Primary care Dr.
Yes
02 2026
Signature
March 25, 2026 at 5:09:29 PM
Psychiatric Provider
Signature
Consent to contact psychiatric provider?
March 25, 2026 at 5:09:29 PM
End of Providers section
Current Medications
Medication list attached separately?
Any concerns or troubling Side Effects with your medications?
No
If yes, please describe:
Just Started Zoloft Sunday 3/22/26 so this is very new to me
Psychiatric Medication
Medication
Zoloft
Dosage/Frequency
25
When prescribed
Side effects
03 2026
just started with 1/2 dose
Medical Medication
Medication
Dosage/Frequency
When prescribed
Side effects
End of Current Medications section
Medical Status
How would you describe your overall health?
(Poor / Below average / Average / Above average / Excellent)
Excellent
Date of last complete physical exam:
02 2026
Please list any significant findings:
Date of last dental exam:
Date of last dental exam:
Please list any significant findings:
Has your life changed because of your health?
Are you currently undergoing medical treatment?
No
No
Current medical treatment
Do you use Medical Marijuana?
No
Do you regularly take pain medication?
No
Please indicate personal concerns with any of the following physical symptoms:
Allergies, Dizziness
Other:
End of Medical Status section
Trauma History
Please indicate if you have ever experienced any of the following:
Accidental/Unexpected Death of Loved One
I told someone
End of Trauma History section
Childhood History: Adverse Childhood Experience (ACE) Questionnaire
2
Did a parent or other adult in the household often…
Swear at you, insult you, put you down, or humiliate you? or
Act in a way that made you afraid that you might be physically hurt?
N
While you were growing up, during your first 18 years of life:
1
Did a parent or other adult in the household often…
Push, grab, slap, or throw something at you? or ever
Hit you so hard that you had marks or were injured?
N
Yes
No
3
Did an adult or person at least 5 years older than you ever…
Touch or fondle you or have you touch their body in a sexual way? or Try to or actually have oral, anal, or vaginal sex with you?
N
4
Did you often feel that…
No one in your family loved you or thought you were important or special? or
Your family didn’t look out for, feel close to, or support each other?
N
5
Did you often feel that…
You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or
Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
N
6
Were your parents ever separated or divorced?
Y
7
Was your mother or stepmother:
Often pushed, grabbed, slapped, or had something thrown at her? or
Sometimes or often kicked, bitten, hit with a fist, or hit with something hard? or
Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
N
8
Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
N
9
Was a household member depressed or mentally ill or did a household member attempt suicide?
N
10
Did a household member go to prison?
N
End of Childhood History: ACE
Mental Health History
Have you ever intentionally harmed yourself or seriously thought about doing so?
No
Have you suffered racial, sexual, or other forms of discrimination?
No
Do you have a history of alcohol or substance abuse?
No
Do you have a history of an eating disorder (restricting, binging, purging)?
No
Any history of gambling, shopping, sexual, or other behavioral addictions?
No
Do you have a history of unstable relationships?
No
Have you frequently changed jobs?
No
Have you ever had problems with your temper or violence?
No
Have you ever been convicted of a misdemeanor or felony?
No
End of Mental Health History
Childhood and Family History
Mississippi
parents
Were you adopted?
No
mother
Were there frequent family moves?
No
Parents:
(Married / Never married / Separated / Divorced)?
Married
Parental Relationship:
Positive, Affectionate, Stable
Infidelity
Mother
New York
Did your mother work when you were a child?
No
Was you mother generally healthy while you were growing up?
Yes
Is your mother still living?
No
If deceased, please provide year of death:
2005
If living, where does she currently live?
Are you in communication with her?
Relationship with your mother growing up:
(Positive / Mixed / Negative / Abusive)
Positive
If separated or divorced, did mother remarry or have another partner?
If yes, describe your relationship with them growing up:
(Positive, Mixed / Negative / Abusive)
Father
Mississippi
Did your father work when you were a child?
Yes
His occupation?
Attorney
Was you father generally healthy while you were growing up?
Yes
Is your father still living?
Yes
If deceased, please provide year of death:
2024
If living, where does he currently live?
Are you in communication with him?
Relationship with father growing up:
(Positive / Mixed / Negative / Abusive)
Positive
If separated or divorced, did father remarry or have another partner?
If yes, describe your relationship with them growing up:
(Positive / Mixed / Negative / Abusive)
Siblings
How many siblings?
2
Please indicate your birth order:
(Oldest / Youngest / Somewhere in the middle)
Youngest
​​Siblings names and ages:
Mark 55
Reeve 51
Are you in communication with some/all of them?
Yes
Do you have any family members living in the area?
No
Any problems with your delivery and birth?
No
Any developmental delays?
No
Childhood medical problems?
No
Any childhood hospitalizations or intense medical/dental procedures?
No
Did you have a favorite pet growing up?
Yes
What was your favorite thing to do as a child?
Going to our summer home in North Carolina with my parents and best friends
During childhood, how did you cope with difficult situations?
walk or play with my beloved childhood dog
Indicate quality and experience of childhood home life (check all that apply):
Positive, Stable
Fun
Options
At what age did you leave home and why?
18 for college
End of Childhood and Family History section
Education History
What type of student were you?
(Above average / Average / Below Average)
Who was most influential or helpful during your school years?
My mom helped me and hired tutors- struggled with adhd
Average
Please indicate your school experience:
(Positive / Negative / Mixed)
Elementary School
Negative
Middle/High School
Positive
College
Mixed
Year of high school graduation:
1999
Did you experience any of the following at school?
Attention difficulties, Learning Difficulties
End of Education History section
Relationship History
Age at first intimate relationship:
16
Any struggles with sexual orientation or sexual identity?
Yes
Are you currently in a long-term relationship?
Yes
If currently married, how old were you at the time of marriage?
27
How old was your spouse at the time of marriage?
30
Do you have children together?
Yes
If previously married, what age were you at the time of that marriage?
When did that marriage end?
Briefly describe why that marriage ended:
Did you have children together?
Please check all that apply to your relationship history:
Positive, Attached, Affectionate, Fun, Stable
Other:
We argue at times but it is over the same things we have always argued about. He thinks I do not put him first or do things to make his life easier--- I blame ADHD-trouble finishing tasks.
End of Relationship History section
Family Mental Health
Alcohol Abuse, Anger Problems, Anxiety, Attentional Difficulties, Depression, Dementia, Eating Disorder
Learning Difficulties, Substance Abuse
Please indicate if any of the following mental health conditions are/were present or suspected in immediate or extended family:
Dad, grandfather (M)
Brother
Grandmother (P)
Dad, brothers
2 brother
DAD
1 Brother
brother
2 brother
Other:
Which family member(s) have negatively impacted you the most?
My second brother who I am very close to has some very toxic behaviors. Also have a step mother who has toxic behaviors as well
Please indicate how significantly you have been impacted:
(Not at all / somewhat / Quite a bit / Greatly)
Quite a bit
End of Family Mental Health section
Strengths and Goals
What are your goals for treatment?
Reduce anxiety, find better way to cope. Establish more discipline in my life and less chaos. Put worries aside and not catastrophize.
When did you last feel emotionally healthy?
I am not sure how to answer this question
What are you wanting to change most about your life?
Internally be more positive. I am positive on the outside. Have a chill attitude that everything will be okay and improve my religious faith. it has struggled since my dad's death in 2024
How have you made it through difficult times before?
Resilience
What do you consider your strengths?
I am high energy
What experience have you enjoyed most over the past week?
I went to a musical with my daughter on Sunday
Please share a positive belief you have about yourself:
I know i am a good person