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
Melissa Sawyer
02 05 1965
Partner/Spouse
Married
Michael Sawyet
08 16 1964
Megan: 30
Mitchell: 24
Baxter
2 sisters, mother
true
Special Education Teachet
Paradise Valley Unified School District
Megan Sawyer
6025013030
Daughter
End of Identifying Information section
Current Concerns
What are you most concerned about now?
Family relations
Depression
Anxiety
Please rate your current level of distress, from 1-10, (1=minimal to 10=extreme):
8
When do you tend to feel the worst?
All day
Please indicate how long you’ve been feeling this way now:
8 days
Have you ever felt this way in the past?
Yes
If so, when and how severe?
I have had these issues for close to 40 years. The level of severity just changes.
What has been done so far to address these concerns?
I am on depression medication and have been in therapy many times throughout these years.
Do you have any negative beliefs about yourself?
Yes
If yes, what are they?
That I am a failure as a mother to my son. That I have no idea how to be a happy person, a rarely feel joy. That I have no purpose. That I am an emotional burden to my daughter.
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:
Serious Problem with Child
Marriage
Financial Stress, 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?
4 Severe - Nearly every day
2. Feeling down, depressed, or hopeless?
4 Severe - Nearly every day
3. Feeling more irritated, grouchy, or more angry than usual?
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?
4 Severe - Nearly every day
8. Avoiding situations that make you anxious?
2 Mild - Several Days
9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs?)
2 Mild - Several Days
10. Feeling that your illnesses are not being taken seriously enough?
1 Slight - Rare
11. Thoughts of actually hurting yourself?
1 Slight - Rare
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?
1 Slight - Rare
16. Unpleasant thoughts, urges, or images that repeatedly enter your mind?
2 Mild - Several Days
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?
2 Mild - Several Days
20. Not feeling close to other people or enjoying your relationship with them?
3 Moderate - More than half the 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
Masters degrer
Are you currently attending school?
No
20 years
Medium
Have you ever been terminated from a job?
No
Medium
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?
Family
Are you satisfied with your home and family life?
No
Rarely
How socially active are you?
Who do you most enjoy spending time with?
My children
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
Low
Please list your favorite activities, interests or hobbies:
Spending time with my children, attending sporting events, reading
Briefly describe how you spend a typical day:
Teaching, cooking, watching tv, sleeping
What do you like most about yourself?
I care about others
Please describe one of your favorite memories:
College and some family vacations
End of Current Status section
Current Relationships
My daughter
Are you currently in a committed romantic relationship?
Yes
If YES, with whom and for how long?
Married for 35 years
Quality of relationship: (Positive / Mixed / Negative)
Negative
Any current romantic relationship conflicts?
Yes
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:
Age at first mental treatment
Why did you seek/receive treatment?
Why did you seek treatment
Have you ever met with a therapist?
Ever met a therapist
Why met a therapist
Therapist name
Therapist locaton
Therapist phone
If you would like me to consult with your previous therapist, please designate and sign your consent below:
Submission date
Have you ever been hospitalized for a mental health condition?
Ever hospitalized for mental health
If yes, please complete below:
Hospitalization 1 date
Hospitalization 1 Location
Hospitalization 1 Reason
Hospitalization 2 date
Hospitalization 2 Location
Hospitalization 2 Reason
Have you taken psychiatric medication in the past?
Psychiatric medication Y/N
If yes, please complete below:
Prev Psych med 1
psych med 1 when
Prev psych med 1 stopped
Prev Psych med 2
psych med 2 when
Prev psych med 2 stopped
Prev Psych med 3
psych med 3 when
Prev psych med 3 stopped
Other support groups or treatment
End of Mental Health Treatment History section
Providers
Primary Care Physician
Primary care Dr name
Dr's phone
Consent to contact
Primary care Dr.
Consent to contact primary Dr
Last visit
Dr's fax
Signature
Todays date
Psychiatric Provider
Psychiatric Provider Name
Psychiatric Provider Phone
Psychiatric last visit
Psychiatric Provider Fax
Signature
Consent to contact psychiatric provider?
Consent to contact psych
Todays date
Other clinical providers
End of Providers section
Current Medications
Medication list attached separately?
Medication list attached separately?
Any concerns or troubling Side Effects with your medications?
Troubling Side Effects with your medications
If yes, please describe:
Troubling Side Effects with your medications
Psychiatric Medication
Medication
Psych Med 1
Dosage/Frequency
Psych Med 1 Dose
Psych Med 2
Psych Med 2 Dose
Psych Med 3
Psych Med 3 Dose
Psych Med 4
Psych Med 4 Dose
Psych Med 5
Psych Med 5 Dose
When prescribed
Side effects
Psych Med 1 date
Psych Med 1 side e
Psych Med 2 date
Psych Med 2 side e
Psych Med 3 date
Psych Med 3 side e
Psych Med 4 date
Psych Med 4 side e
Psych Med 5 date
Psych Med 5 side e
Medical Medication
Medication
Med 1
Dosage/Frequency
Med 1 Dose
Med 2
Med 2 Dose
Med 3
Med 3 Dose
Med 4
Med 4 Dose
Med 5
Med 5 Dose
When prescribed
Med 1 date
Side effects
Med 1 Side ef
Med 2 date
Med 2 side ef
Med 3 date
Med 3 side ef
Med 4 date
Med 4 side ef
Med 5 date
Med 5 side ef
End of Current Medications section
Medical Status
How would you describe your overall health?
(Poor / Below average / Average / Above average / Excellent)
Overall health
Date of last complete physical exam:
Date of last complete physical exam:
Please list any significant findings:
List any significant findings
Date of last dental exam:
Date of last dental exam:
Please list any significant findings:
Please list any significant findings:
Has your life changed because of your health?
Are you currently undergoing medical treatment?
Life changed because of health
Currently undergoing health treatment
Current medical treatment
Current medical treatment
Do you use Medical Marijuana?
Medical Marijuana
Do you regularly take pain medication?
Pain meds
Please indicate personal concerns with any of the following physical symptoms:
Physical symptoms 1
Physical concerns 2
Physical concerns 3
Other:
Other physical concerns
End of Medical Status section
Trauma History
Please indicate if you have ever experienced any of the following:
Trauma 1
Trauma 2
Trauma 3
Typical response
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?
ACE-2
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?
ACE-1
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?
ACE-3
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?
ACE-4
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?
ACE-5
6
Were your parents ever separated or divorced?
ACE-6
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?
ACE-7
8
Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
ACE-8
9
Was a household member depressed or mentally ill or did a household member attempt suicide?
ACE-9
10
Did a household member go to prison?
ACE-10
End of Childhood History: ACE
Mental Health History
Have you ever intentionally harmed yourself or seriously thought about doing so?
intentionally harmed yourself
Have you suffered racial, sexual, or other forms of discrimination?
Suffered discrimination
Do you have a history of alcohol or substance abuse?
alcohol or substance abuse
Do you have a history of an eating disorder (restricting, binging, purging)?
eating disorder
Any history of gambling, shopping, sexual, or other behavioral addictions?
behavioral disorder
Do you have a history of unstable relationships?
unstable relationships
Have you frequently changed jobs?
frequent job changes
Have you ever had problems with your temper or violence?
problems w. temper / violence
Have you ever been convicted of a misdemeanor or felony?
convictions
End of Mental Health History
Childhood and Family History
Where born / raised
Who raised you
Were you adopted?
Adopted?
Who was most supportive
Were there frequent family moves?
Frequent moves
Parents:
(Married / Never married / Separated / Divorced)?
Parents married?
Parental Relationship:
Parental Relations 1
Parental Relations 2
Parental Relations 3
Mother
Mother born where
Did your mother work when you were a child?
Did your mother work when you were a child?
Mothers occupation
Was you mother generally healthy while you were growing up?
Mother healthy
Is your mother still living?
Mother living
If deceased, please provide year of death:
Mother died
If living, where does she currently live?
Mother location
Are you in communication with her?
Communicate w mother
Relationship with your mother growing up:
(Positive / Mixed / Negative / Abusive)
Relationship w. mother
If separated or divorced, did mother remarry or have another partner?
Mother re-partnered?
If yes, describe your relationship with them growing up:
(Positive, Mixed / Negative / Abusive)
Relationship with remarried mother
Father
Father born where
Did your father work when you were a child?
father work Y/N
His occupation?
His occupation
Was you father generally healthy while you were growing up?
Father generally healthy Y/N
Is your father still living?
Father still living Y/N
If deceased, please provide year of death:
Date of death
If living, where does he currently live?
Are you in communication with him?
Fathers location
Relationship with father growing up:
(Positive / Mixed / Negative / Abusive)
Relationship w. father
Father communicating
If separated or divorced, did father remarry or have another partner?
Father repartnered Y/N
If yes, describe your relationship with them growing up:
(Positive / Mixed / Negative / Abusive)
Relationship w remarried father
Siblings
How many siblings?
Siblings
Please indicate your birth order:
(Oldest / Youngest / Somewhere in the middle)
Birth order
Siblings names and ages:
Siblings list
Are you in communication with some/all of them?
Communicate w siblings
Do you have any family members living in the area?
Family local
Any problems with your delivery and birth?
Problems at birth
Any developmental delays?
developmental delays
Childhood medical problems?
Childhood medical problems
Any childhood hospitalizations or intense medical/dental procedures?
childhood hospitalizations
Did you have a favorite pet growing up?
favorite pet
What was your favorite thing to do as a child?
favorite thing to do as a child
During childhood, how did you cope with difficult situations?
Childhood coping mechanism
Indicate quality and experience of childhood home life (check all that apply):
Childhood 1
Childhood 2
Childhood 3
Childhood 4
Childhood 5
Options
At what age did you leave home and why?
At what age did you leave home and why?
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?
most influential or helpful during school
Short text
Please indicate your school experience:
(Positive / Negative / Mixed)
Elementary School
Elementary experience
Middle/High School
High school experience
College
College experience
Year of high school graduation:
Grad year
Did you experience any of the following at school?
School experience 1
School experience 2
School experience 3
End of Education History section
Relationship History
Age at first intimate relationship:
First intimacy
Any struggles with sexual orientation or sexual identity?
struggles with sexual orientation
Are you currently in a long-term relationship?
in a long-term relationship
If currently married, how old were you at the time of marriage?
Age at current marriage
How old was your spouse at the time of marriage?
Age of spouse at wedding
Do you have children together?
Children?
If previously married, what age were you at the time of that marriage?
Age at previous marriage
When did that marriage end?
When did marriage end
Briefly describe why that marriage ended:
Briefly describe why that marriage ended:
Did you have children together?
children together?
Please check all that apply to your relationship history:
Relationship 1
Relationship 2
Relationship 3
Other:
Other:
End of Relationship History section
Family Mental Health
List of tags 1
List of tags 2
Please indicate if any of the following mental health conditions are/were present or suspected in immediate or extended family:
Alcohol
Anger
Anxiety
Attention difficulties
Autism
Bipolar
Borderline
Depression
Dementia
Eating disorder
Gambling
Health prob
Learning difficulties
Legal problems
Memory
Mental retardation
Narcissistic
Obsessive compulsive
PTSD
Schitzophrenia
Substance abuse
Suicide attempt
Suicide completed
Violent behavior
Other mental prob
Other:
Other family mental health problems
Which family member(s) have negatively impacted you the most?
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)
how significantly you have been impacted:
End of Family Mental Health section
Strengths and Goals
What are your goals for treatment?
Goals for treatment
When did you last feel emotionally healthy?
When did you last feel emotionally healthy?
What are you wanting to change most about your life?
What are you wanting to change most about your life?
How have you made it through difficult times before?
How have you made it through difficult times before?
What do you consider your strengths?
What do you consider your strengths?
What experience have you enjoyed most over the past week?
What experience have you enjoyed most over the past week?
Please share a positive belief you have about yourself:
Please share a positive belief you have about yourself: