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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
Hilary Berko
12 17 1968
Partner/Spouse
Married
Frank Johnson
06 04 1966
Rachel Johnson 31
Deceased. Moxie - dog Bob - cat
Mom Cecile Berko. Brother/sister-in-law. Adam and Pat Berko
true
Attorney
Maricopa County
Frank Johnson
6026211485
Husband
End of Identifying Information section
Current Concerns
What are you most concerned about now?
Stress/anxiety revolving around death of mother-in-law
Please rate your current level of distress, from 1-10, (1=minimal to 10=extreme):
6
When do you tend to feel the worst?
Throughout day depending on situation
Please indicate how long you’ve been feeling this way now:
4 months
Have you ever felt this way in the past?
No
If so, when and how severe?
What has been done so far to address these concerns?
Conversations with spouse. Meeting with Risa
Do you have any negative beliefs about yourself?
No
If yes, what are they?
Regarding weight. Regarding relationships
Specify which areas of your life are affected by this problem:
Physical, Home, Family, Relationships
Other?
End of Current Concerns section
Stressful Life Events
Please indicate if any of the following have occurred within the past 12 months:
Death of Immediate Family Member, Serious Problem with Child
Financial Stress
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?
2 Mild - Several Days
2. Feeling down, depressed, or hopeless?
2 Mild - Several Days
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?
3 Moderate - More than half the days
7. Feeling panic or being frightened?
0 None - Not at all
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?
0 None - Not at all
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?
3 Moderate - More than half the 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?
2 Mild - Several Days
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
Doctorate
Are you currently attending school?
No
Law
30 years
High
Have you ever been terminated from a job?
No
Low
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, Family
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
How important is religion and/or spirituality in your life?
Very / Somewhat / Not at all
Somewhat
Are you physically active? Yes / Sometimes / No
Current satisfaction with lifestyle, hobbies, activities:
High / Medium / Low
Sometimes
Medium
Please list your favorite activities, interests or hobbies:
Briefly describe how you spend a typical day:
Work. Watch tv. Run errands. Do housework.
What do you like most about yourself?
Helping others
Please describe one of your favorite memories:
Party friends had in law school for me
End of Current Status section
Current Relationships
Husband/mom
Are you currently in a committed romantic relationship?
Yes
If YES, with whom and for how long?
Frank - 27 years
Quality of relationship: (Positive / Mixed / Negative)
Positive
Any current romantic relationship conflicts?
No
Are you concerned about any potential violence?
Yes
Any recent breakups?
No
If you have children, are there any current relationship difficulties?
Yes
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:
39
Why did you seek/receive treatment?
Felt depressed and anxious
Have you ever met with a therapist?
Yes
Off/on 20 years. Usually being overwhelmed with family issues
If you would like me to consult with your previous therapist, please designate and sign your consent below:
June 27, 2026 at 3:04:59 AM
Have you ever been hospitalized for a mental health condition?
No
If yes, please complete below:
Have you taken psychiatric medication in the past?
Yes
If yes, please complete below:
Bupropion
Lamictal
Risperdone
End of Mental Health Treatment History section
Providers
Primary Care Physician
Sadan Patel
4805845959
Consent to contact
Primary care Dr.
Yes
07 2026
Signature
June 27, 2026 at 3:05:05 AM
Psychiatric Provider
Heidi Pence
4809491100
06 2026
Signature
Consent to contact psychiatric provider?
Yes
June 27, 2026 at 3:05:05 AM
End of Providers section
Current Medications
Medication list attached separately?
Any concerns or troubling Side Effects with your medications?
No
If yes, please describe:
Psychiatric Medication
Medication
Lamictal
Dosage/Frequency
Risperdone
3mg once a day
Bupropion
150 once a day
Clonazepam
.5/1 mg as needed
When prescribed
Side effects
11 2023
Medical Medication
Medication
Mounjaro
Dosage/Frequency
10.5
Atorvistatin
Jardience
25mg
Aspirin
80mg
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)
Average
Date of last complete physical exam:
07 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?
Yes
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, Diabetes
Menopause
Obesity, Weight Loss
Other:
End of Medical Status section
Trauma History
Please indicate if you have ever experienced any of the following:
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?
N
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?
Yes
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?
Yes
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
St. Petersburg FL
Mom/Dad
Were you adopted?
No
Mom/Dad
Were there frequent family moves?
No
Parents:
(Married / Never married / Separated / Divorced)?
Married
Parental Relationship:
Positive, Close, Affectionate, Stable
Mother
Chicago
Did your mother work when you were a child?
Yes
Realtor
Was you mother generally healthy while you were growing up?
Yes
Is your mother still living?
Yes
If deceased, please provide year of death:
If living, where does she currently live?
Florida
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
Dayton OH
Did your father work when you were a child?
Yes
His occupation?
Financial advisor
Was you father generally healthy while you were growing up?
Yes
Is your father still living?
No
If deceased, please provide year of death:
2019
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?
1
Please indicate your birth order:
(Oldest / Youngest / Somewhere in the middle)
Youngest
​​Siblings names and ages:
Adam - 60
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?
Yes
Did you have a favorite pet growing up?
No
What was your favorite thing to do as a child?
During childhood, how did you cope with difficult situations?
Indicate quality and experience of childhood home life (check all that apply):
Positive, Loving, Stable
Fun
Options
At what age did you leave home and why?
17 - 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?
Mom
Above Average
Please indicate your school experience:
(Positive / Negative / Mixed)
Elementary School
Positive
Middle/High School
Negative
College
Positive
Year of high school graduation:
1986
Did you experience any of the following at school?
Social difficulties, Isolation
End of Education History section
Relationship History
Age at first intimate relationship:
18
Any struggles with sexual orientation or sexual identity?
No
Are you currently in a long-term relationship?
Yes
If currently married, how old were you at the time of marriage?
32
How old was your spouse at the time of marriage?
34
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, Affectionate, Communicative, Fun, Stable
Other:
End of Relationship History section
Family Mental Health
Please indicate if any of the following mental health conditions are/were present or suspected in immediate or extended family:
Other:
Which family member(s) have negatively impacted you the most?
Please indicate how significantly you have been impacted:
(Not at all / somewhat / Quite a bit / Greatly)
End of Family Mental Health section
Strengths and Goals
What are your goals for treatment?
To reduce anxiety and learn tools to navigate life
When did you last feel emotionally healthy?
December 2026
What are you wanting to change most about your life?
Weight issues. Anxiety
How have you made it through difficult times before?
Push through. Communication with spouse and parents
What do you consider your strengths?
Leadership. Advice giving
What experience have you enjoyed most over the past week?
Dinner at restaurant
Please share a positive belief you have about yourself:
I am a kind person
End of Strengths and Goals section
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