CALL NOW 602-478-1477
(F) 602-773-0998
RISA E. NEWELL, Ph.D., L.L.C.
LICENSED CLINICAL PSYCHOLOGIST
Patient Evaluation - VIEWING and PRINT
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.
You may also just bring this form with you to your Initial Evaluation appointment.
Identifying Information
March 16, 2026
Submitted
DR. RISA NEWELL
* Required
11 01 1961
Alone, Partner/Spouse, Children, Parents/Other Relatives, Roommates, Pets, Other
Single, Married, Partnered, Divorced, Widowed
fred
01 11 1911
bob, sue
frank
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Current Concerns
What are you most concerned about now?
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Please rate your current level of distress, from 1-10, (1=minimal to 10=extreme):
10
When do you tend to feel the worst?
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Please indicate how long you’ve been feeling this way now:
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Have you ever felt this way in the past?
Yes
If so, when and how severe?
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What has been done so far to address these concerns?
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Do you have any negative beliefs about yourself?
Yes
If yes, what are they?
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Specify which areas of your life are affected by this problem:
Physical, Home, Family, Relationships, Work/School, Financial
Legal
Other?
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Stressful Life Events
Please indicate if any of the following have occurred within the past 12 months:
Death of Immediate Family Member, Death of Close Friend, Serious Problem with Child, Health Problem in Close Family Member, Terminal Illness, Became Disabled, Serious Personal Injury
Marriage, Change in Residence, Pregnancy, Miscarriage or Abortion, Infertility, Separation or Divorce, Custody Dispute
Significant Legal Problems, New job, Financial Stress, Work Stress, Job Loss, Retirement, Death of Favorite Pet
Other:
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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?
3 Moderate - More than half the days
3. Feeling more irritated, grouchy, or more angry than usual?
4 Severe - Nearly every day
4. Sleeping less than usual, but still have a lot of energy?
4 Severe - Nearly every day
5. Starting lots more projects than usual or doing more risky things than usual?
2 Mild - Several Days
6. Feeling nervous, anxious, frightened, worried, or on edge?
1 Slight - Rare
7. Feeling panic or being frightened?
2 Mild - Several Days
8. Avoiding situations that make you anxious?
1 Slight - Rare
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?
3 Moderate - More than half the days
11. Thoughts of actually hurting yourself?
4 Severe - Nearly every day
12. Hearing things other people couldn't hear, such as voices even when no one was around?
2 Mild - Several Days
13. Feeling that someone could hear your thoughts, or that you could hear what another person was thinking?
2 Mild - Several Days
14. Problems with sleep that affected your sleep quality overall?
0 None - Not at all
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?
3 Moderate - More than half the days
18. Feeling detached or distant from yourself, your body, your physical surroundings, or your memories?
2 Mild - Several Days
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?
3 Moderate - More than half the days
21. Drinking at least 4 drinks of any kind of alcohol in a single day?
2 Mild - Several Days
22. Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco?
1 Slight - Rare
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)]?
2 Mild - Several Days
Current Status
22
Are you currently attending school?
Yes
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High
High
Have you ever been terminated from a job?
Yes
Are you currently receiving disability?
Yes
Are you an active member of the Armed Forces?
Yes
Have you ever served in the military?
Yes
Were you ever in combat?
Yes
Do you have an illness or injury related to your service
Yes
Partner, Family, Friends, Neighbors, Church/Spiritual, Community, Other
Are you satisfied with your home and family life?
How socially active are you?
Yes
Very
Who do you most enjoy spending time with?
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How important is religion and/or spirituality in your life?
Very / Somewhat / Not at all
Very
Are you physically active? Yes / Sometimes / No
Yes
Current satisfaction with lifestyle, hobbies, activities:
High / Medium / Low
High
Please list your favorite activities, interests or hobbies:
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Briefly describe how you spend a typical day:
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What do you like most about yourself?
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Please describe one of your favorite memories:
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Current Relationships
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Are you currently in a committed romantic relationship?
Yes
If YES, with whom and for how long?
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Quality of relationship: (Positive / Mixed / Negative)
Positive
Any current romantic relationship conflicts?
Yes
Are you concerned about any potential violence?
Yes
Any recent breakups?
Yes
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?
Yes
Any relationship problems with other family members, (parents, siblings, etc.)?
Yes
Any conflict with others outside of family, (friends, coworkers, neighbors, etc.)?
Yes
To whom are you closest?
Physical, Home, Family, Relationships, Work/School, Financial
Physical, Home, Family, Relationships, Work/School, Financial
Mental Health Treatment History
Age at first mental health treatment:
9
Why did you seek/receive treatment?
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Have you ever met with a therapist?
Yes
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If you would like me to consult with your previous therapist, please provide therapist information and sign your consent here:
March 16, 2026 at 7:37:29 AM
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Have you ever been hospitalized for a mental health condition?
Yes
If yes, please complete below:
1999
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Have you taken psychiatric medication in the past?
Yes
If yes, please complete below:
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Any other psychiatric medication:
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Providers
Primary Care Physician
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3049539088
12 2022
0334977593
Signature
Consent to contact Primary care Dr.
Yes
March 16, 2026 at 7:37:30 AM
Psychiatric Provider
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9837508395
03 1922
0497545924
Signature
Consent to contact psychiatric provider?
Yes
March 16, 2026 at 7:37:30 AM
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Current Medications
Medication list attached separately?
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Any concerns or troubling Side Effects with your medications?
Yes
If yes, please describe:
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Psychiatric Medication
Medication
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Dosage/Frequency
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When prescribed
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Medical Medication
Medication
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Dosage/Frequency
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When prescribed
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Medical Status
How would you describe your overall health?
(Poor / Below average / Average / Above average / Excellent)
Poor
Date of last complete physical exam:
03 2022
Please list any significant findings:
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Date of last dental exam:
01 2022
Please list any significant findings:
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Has your life changed because of your health?
Are you currently undergoing medical treatment?
Yes
Yes
Current medical treatment
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Please list any major illnesses, events or accidents from your medical history:
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Do you use Medical Marijuana?
Yes
Do you regularly take pain medication?
Yes
Please indicate personal concerns with any of the following physical symptoms:
Allergies, Alzheimer’s Disease, Arthritis, Asthma, Atrial Fibrillation, Back Pain, Binge Eating, Brain Injury, Cancer, Cholesterol, Chronic Pain, Congestive Heart Failure, COPD, Dental Problems, Diabetes, Dizziness, Dry Mouth, Epilepsy, Fainting Spells, Fatigue
Fibromyalgia, Gastrointestinal Issues, Gynecological Problems, Hair Loss, Head Injury, Hearing Problems, Heart Disease, Hepatitis, HIV, Hormones, Hypertension, Incontinence, Infertility, Insomnia, Kidney Disease, Limited Mobility, Memory Problems, Menopause, Migraine Headaches, Meniere’s Disease
Multiple Sclerosis, Muscle Cramps, Nausea / Vomiting, Nightmares, Numbness, Obesity, Osteoporosis, Parkinson’s Disease, Pregnancy, Prostate, Seizures, Sexual Problems, Skin Disorder, Stroke, Swelling, Terminal Illness, Thyroid Problems, Vision Problems, Weight Loss
Other please specify):
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Trauma History
Please indicate if you have ever experienced any of the following:
Death of a Child, Suicide of Loved One, Accidental/Unexpected Death of Loved One, Death of Close Friend, Serious Accident, Medical Trauma
Miscarriage or Abortion, Physical Sexual or Emotional Abuse, Corporal Punishment, Foster Care, Bullying, Discrimination
Assault or Rape, Domestic Violence, Violent Crime, Witnessing Violence, Homelessness
Other (please specify):
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I told someone, Help and support, Effective treatment
I did not tell anyone, Unsupportive, Rejecting or blaming
Lasting emotional symptoms, Lasting physical symptoms, Recurrent trauma triggers
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?
Y
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?
Y
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?
Y
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?
Y
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?
Y
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?
Y
8
Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
Y
9
Was a household member depressed or mentally ill or did a household member attempt suicide?
Y
10
Did a household member go to prison?
Y
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?
Yes
Do you have a history of alcohol or substance abuse?
Yes
Do you have a history of an eating disorder (restricting, binging, purging)?
Yes
Any history of gambling, shopping, sexual, or other behavioral addictions?
Yes
Do you have a history of unstable relationships?
Yes
Have you frequently changed jobs?
Yes
Have you ever had problems with your temper or violence?
Yes
Have you ever been convicted of a misdemeanor or felony?
Yes
Childhood and Family History
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Were you adopted?
Yes
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Were there frequent family moves?
Yes
Parents:
(Married / Never married / Separated / Divorced)?
Married
Parental Relationship:
Positive, Close, Affectionate, Stable
Variable, Distant, Negative, Unstable
Conflictual, Infidelity, Abusive, Violent
Mother
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Did your mother work when you were a child?
Yes
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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?
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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?
Yes
If yes, describe your relationship with them growing up:
(Positive, Mixed / Negative / Abusive)
Positive
Father
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Did your father work when you were a child?
Yes
His occupation?
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Was you father generally healthy while you were growing up?
Yes
Is your father still living?
Yes
If living, where does he currently live?
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If deceased, please provide year of death:
1990
Are you in communication with him?
Yes
Relationship with father growing up:
(Positive / Mixed / Negative / Abusive)
If separated or divorced, did father remarry or have another partner?
Yes
If yes, describe your relationship with them growing up:
(Positive / Mixed / Negative / Abusive)
Positive
Siblings
Please indicate your birth order:
(Oldest / Youngest / Somewhere in the middle)
Oldest
How many siblings?
8
Siblings names and ages:
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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?
Yes
Childhood medical problems?
Yes
Any childhood hospitalizations or intense medical/dental procedures?
Yes
Did you have a favorite pet growing up?
Yes
What was your favorite thing to do as a child?
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During childhood, how did you cope with difficult situations?
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Indicate quality and experience of childhood home life (check all that apply):
Positive, Loving, Stable
Fun, Variable, Unstable
Negative, Chaotic, Neglectful
Rejecting, Abusive, Violent
Poverty, Arrests, Alcohol/Drug Abuse
Options
At what age did you leave home and why?
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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?
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Above Average
Please indicate your school experience:
(Positive / Negative / Mixed)
Elementary School
Positive
Middle/High School
Positive
College
Positive
Year of high school graduation:
1979
Did you experience any of the following at school?
Attention difficulties, Learning Difficulties, Hurtful Teachers, Repeated Grade
Social difficulties, Isolation, Bullying, Sexual Behavior
Behavioral problems, Substance Abuse, Truancy
Relationship History
Age at first intimate relationship:
7
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?
17
How old was your spouse at the time of marriage?
55
Do you have children together?
Yes
If previously married, what age were you at the time of that marriage?
9
When did that marriage end?
1970
Briefly describe why that marriage ended:
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Did you have children together?
Yes
Family Mental Health
Alcohol Abuse, Anger Problems, Anxiety, Attentional Difficulties, Autism, Bipolar Disorder, Borderline Personality, Depression, Dementia, Eating Disorder, Gambling Problem, Health Problems
Learning Difficulties, Legal Problems, Memory Impairment, Mental Retardation, Narcissistic Personality, Obsessive-Compulsive, Post-Traumatic Stress, Schizophrenia, Substance Abuse, Suicide Attempts, Suicide Completed, Violent Behavior
Please indicate if any of the following mental health conditions are/were present or suspected in immediate or extended family:
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Which family member(s) have negatively impacted you the most?
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Please indicate how significantly you have been impacted:
(Not at all / somewhat / Quite a bit / Greatly)
Not at all
Strengths and Goals
What are your goals for treatment?
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When did you last feel emotionally healthy?
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What are you wanting to change most about your life?
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How have you made it through difficult times before?
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What do you consider your strengths?
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What experience have you enjoyed most over the past week?
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Please share a positive belief you have about yourself:
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