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
Juliaette Chamberlain
11 02 1980
Partner/Spouse, Children, Pets
Married
Jerry Chamberlain
09 05 1973
William age 15, Jack age 13, Cy age 12
Rowdy, beloved family dog
Mother Judith, Father Bruce live in town and help a lot with the boys, Mother-in-law Merrie Jo lives in town too
true
Director, Graduate Medical Education
Creighton University School of Medicine
Jerry Chamberlain
8168855117
Spouse
End of Identifying Information section
Current Concerns
What are you most concerned about now?
Currently a lot of stress and anxiety around my health - I've been having back and muscle issues that I'm working to get diagnosed. I think it brings more anxiety in me because two of my boys are type 1 diabetics, my mom has had heart failure for many years, and my mother in law is currently in a skilled nursing facility for her health. I am always concerned about my kids for a million reasons. Work also tends to cause me a lot of stress as I strive to perform at a very high level.
Please rate your current level of distress, from 1-10, (1=minimal to 10=extreme):
7
When do you tend to feel the worst?
Night - I keep myself busy during the day but have started having sleep issues, waking up at night and in the morning with worry.
Please indicate how long you’ve been feeling this way now:
Three weeks
Have you ever felt this way in the past?
Yes
If so, when and how severe?
My youngest son Cy had a potentially very serious condition about 1.5 years ago - going through that testing felt the same way. That time had me more at a 10 level.
What has been done so far to address these concerns?
So far I've used tools from previous therapy; recognize the catastrophizing behavior, trying to stop the unhelpful thoughts that don't have evidence. I am also a very religious person so I've been trying to make time for prayer and journaling. I also relish in physical activity so also making time to exercise has been key.
Do you have any negative beliefs about yourself?
Yes
If yes, what are they?
Mostly I get mad and frustrated with myself that I keep getting so anxious despite the work I do to try and manage it.
Specify which areas of your life are affected by this problem:
Physical
Other?
End of Current Concerns section
Stressful Life Events
Please indicate if any of the following have occurred within the past 12 months:
Health Problem in Close Family Member
Work 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?
0 None - Not at all
2. Feeling down, depressed, or hopeless?
0 None - Not at all
3. Feeling more irritated, grouchy, or more angry than usual?
0 None - Not at all
4. Sleeping less than usual, but still have a lot of energy?
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?
3 Moderate - More than half the days
8. Avoiding situations that make you anxious?
3 Moderate - More than half the days
9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs?)
4 Severe - Nearly every day
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?
4 Severe - Nearly every day
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?
1 Slight - Rare
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?
1 Slight - Rare
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
Bachelors Degree
Are you currently attending school?
No
Business
5 years
High
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, Family, Friends, Church/Spiritual
Are you satisfied with your home and family life?
Yes
Somewhat
How socially active are you?
Who do you most enjoy spending time with?
My spouse, kids, and parents (including MIL)
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:
Exercise, Reading, Travel
Briefly describe how you spend a typical day:
Wake up 5-6am and exercise
6-7am get kids ready for school
7am get ready for work
8-5:30 work (in an office building downtown)
5:30-8 dinner, kids sports
8-10 try to read or do bible study, put kids to bed
What do you like most about yourself?
I err on the side of a positive attitude.
Please describe one of your favorite memories:
My boys being born and being so happy that they were mine.
End of Current Status section
Current Relationships
My husband
Are you currently in a committed romantic relationship?
Yes
If YES, with whom and for how long?
Jerry (my husband) and I have been married for almost 18 years.
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?
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:
40
Why did you seek/receive treatment?
I had an event where I had gone back to work and had been at my job for about a year. My boss and her boss quit at the same time, and it was three months before we were onboarding 100 new doctors and changing the employer of 300 doctors. I got immediatly promoted and all fo that fell into my lap, despite not having much experience in the role. I started experiencing a lot of stress (I remember leaving a voicemail and I couldn't remember my phone number because my head was spinning so much). Due to this stress, I had friends visiting, and I tried a THC gummy to see if it would help. It did the exact opposite and ignited even worse anxiety and a fight or flight response for over 2 weeks where I couldn't sleep, couldn't focus - all while the most important parts of my work were taking place. I went to a doctor who was amazing and put me on a temporarly sleep aid and SSId, and referred me to Dr. Keen.
Have you ever met with a therapist?
Yes
Based on that experience I first met with Dr. Keen.
Dr. Keen
n/a - retired
4804300192
If you would like me to consult with your previous therapist, please designate and sign your consent below:
January 23, 2026 at 5:39:54 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?
Yes
If yes, please complete below:
Trazdodone, 25mg-50mg
With two boys that are type 1, I have to check their blood sugar in the middle of the night - cannot sleep too soundly.
Lexapro (6 months)
Felt better, felt like it got me through what I needed it to
Listening to podcasts
End of Mental Health Treatment History section
Providers
Primary Care Physician
Hannah Hakes, PA
4806146001
Consent to contact
Primary care Dr.
Yes
12 2025
Signature
January 23, 2026 at 5:39:55 PM
Psychiatric Provider
N/A
Signature
Consent to contact psychiatric provider?
January 23, 2026 at 5:39:55 PM
End of Providers section
Current Medications
Medication list attached separately?
Any concerns or troubling Side Effects with your medications?
If yes, please describe:
Psychiatric Medication
Medication
Dosage/Frequency
When prescribed
Side effects
Medical Medication
Medication
Progesterone
Dosage/Frequency
100mg/1 day
Testosterone
15mg/ml
When prescribed
10 2025
Side effects
None
11 2025
None
End of Current Medications section
Medical Status
How would you describe your overall health?
(Poor / Below average / Average / Above average / Excellent)
Above Average
Date of last complete physical exam:
05 2025
Please list any significant findings:
Date of last dental exam:
Date of last dental exam:
Please list any significant findings:
I've had to have a significant amount of dental work lately - 2 crowns, a root canal, 2 fillings
Has your life changed because of your health?
Are you currently undergoing medical treatment?
No
Yes
Current medical treatment
About to start PT for back, seeing a physician for perimenopause treatment and to help optimize health (Valley Healthspan, Dr. Olson)
Do you use Medical Marijuana?
No
Do you regularly take pain medication?
No
Please indicate personal concerns with any of the following physical symptoms:
Back Pain
Hormones, Insomnia
Muscle Cramps
Other:
End of Medical Status section
Trauma History
Please indicate if you have ever experienced any of the following:
Medical Trauma
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?
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
Virginia
Mom & Dad
Were you adopted?
Mom & Dad
Were there frequent family moves?
No
Parents:
(Married / Never married / Separated / Divorced)?
Married
Parental Relationship:
Positive, Close, Affectionate, Stable
Conflictual
Mother
South Carolina
Did your mother work when you were a child?
Yes
Teacher
Was you mother generally healthy while you were growing up?
No
Is your mother still living?
Yes
If deceased, please provide year of death:
If living, where does she currently live?
Phoenix
Are you in communication with her?
Yes
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
Washington DC
Did your father work when you were a child?
Yes
His occupation?
CPA
Was you father generally healthy while you were growing up?
Yes
Is your father still living?
Yes
If deceased, please provide year of death:
If living, where does he currently live?
Are you in communication with him?
Phoenix
Relationship with father growing up:
(Positive / Mixed / Negative / Abusive)
Positive
Yes
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:
Older brother Barton, age 48
Are you in communication with some/all of them?
Yes
Do you have any family members living in the area?
Yes
Any problems with your delivery and birth?
Yes
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?
Be with my friends
During childhood, how did you cope with difficult situations?
Talk to my close friends (still friends with them to this day)
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 to attend 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?
Parents
Above Average
Please indicate your school experience:
(Positive / Negative / Mixed)
Elementary School
Positive
Middle/High School
Positive
College
Positive
Year of high school graduation:
1998
Did you experience any of the following at school?
End of Education History section
Relationship History
Age at first intimate relationship:
20
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?
27
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, Attached, Affectionate, Communicative, Fun, Stable
Conflictual
Other:
End of Relationship History section
Family Mental Health
Anxiety, Dementia, Health Problems
Please indicate if any of the following mental health conditions are/were present or suspected in immediate or extended family:
Father
Grandmother
Mother (heart failure)
Other:
Which family member(s) have negatively impacted you the most?
I am very fortunate here - nobody comes to mind
Please indicate how significantly you have been impacted:
(Not at all / somewhat / Quite a bit / Greatly)
Not at all
End of Family Mental Health section
Strengths and Goals
What are your goals for treatment?
Get a better handle on managing my anxiety so I can be my strongest self. Have a support system set-up for the very difficult life experiences I know will continue to come my way.
When did you last feel emotionally healthy?
September 2025 - I did a cut for my weight and was eating quite healthy and a bit restricted
What are you wanting to change most about your life?
Manage chronic stress & anxiety. Set my life so I feel more in control vs. reactive.
How have you made it through difficult times before?
Prayer, exercise, work, journaling, trying to not focus so much on myself
What do you consider your strengths?
Positive attitude, loving personality, innate curiosity and love of people.
What experience have you enjoyed most over the past week?
Watching my son Jack score during his basketball game, riding bikes to the bakery with my son William, playing ping pong with my son Cy.
Please share a positive belief you have about yourself:
Overall I am strong and have many blessings (though I feel like I swing to extremes here - I can go to feeling scared pretty radically).