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
Jill Story
* Required
08 29 1974
Roommates
Single
Katie (dog)
Mom (Diana), Brother (Michael), Sister (Suzanne)
true
Training Specialist
Advarra
Diana Ashley
mother
4802595486
Current Concerns
What are you most concerned about now?
1) I have a lot of past trauma issues that impact my relationship with food. That is a long term thing to work on.
2) I need to manage my stress at work over the next three months while we work through a temporary increase in expected training volume.
Please rate your current level of distress, from 1-10, (1=minimal to 10=extreme):
3
When do you tend to feel the worst?
1) I tend to feel emotional/sad when I eat even a little past comfortably full.
2) I get overwhelmed when I need to complete a short term task on a hard deadline that keeps me late at work when I'm tired. I'm much better first thing in the morning.
Please indicate how long you’ve been feeling this way now:
1) Getting sad when I realize I'm full is relatively new, like the last year, but food issues are lifelong.
2) Getting overwhelmed when I'm tired is a long term problem, but it's especially a problem in my current job that I started last year.
Have you ever felt this way in the past?
Yes
If so, when and how severe?
Intermittently over the past 20 years.
What has been done so far to address these concerns?
I have built a library of coping skills around stress and anxiety. My medications for depression/PTSD/anxiety are stable and I take them as prescribed.
Do you have any negative beliefs about yourself?
Yes
If yes, what are they?
I have a belief that it's impossible for me to be in a romantic relationship because of past trauma and lack of experience in relationships. I think the underlying belief is that I am damaged.
Specify which areas of your life are affected by this problem:
Physical, Family, Relationships, Work/School
Other?
Stressful Life Events
Please indicate if any of the following have occurred within the past 12 months:
New job, Work Stress
Other:
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?
1 Slight - Rare
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?
0 None - Not at all
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?
1 Slight - Rare
7. Feeling panic or being frightened?
0 None - Not at all
8. Avoiding situations that make you anxious?
2 Mild - Several Days
9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs?)
1 Slight - Rare
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?
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?
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
Current Status
Some graduate school
Are you currently attending school?
No
Speech-language pathology
10 months in current job, 3 years at current employer
High
Medium
Have you ever been terminated from a job?
No
Are you currently receiving disability?
No
Are you an active member of the Armed Forces?
No
Have you ever served in the military?
No
Were you ever in combat?
No
Do you have an illness or injury related to your service
No
Family
Are you satisfied with your home and family life?
How socially active are you?
Yes
Rarely
Who do you most enjoy spending time with?
I have some friends I enjoy socializing with, and I am close to my mother.
How important is religion and/or spirituality in your life?
Very / Somewhat / Not at all
Somewhat
Are you physically active? Yes / Sometimes / No
No
Current satisfaction with lifestyle, hobbies, activities:
High / Medium / Low
Medium
Please list your favorite activities, interests or hobbies:
I am a really avid reader/listener to audiobooks. I also play some video games and am very interested in world events.
Briefly describe how you spend a typical day:
I wake up before my alarm at 5, work from home from 7-3, then snuggle with my dog for an hour or two after work/before dinner while either napping or listening to an audiobook. Then I eat dinner and either watch the news or play a strategy game or a cozy game before I go to bed. Ideally I start to go to bed at 8. I tend to wake up a lot at night and I have to be disciplined about going straight back to sleep and not getting up at a ridiculous hour (I consider getting up before 4 to be too early).
What do you like most about yourself?
I love to learn new things. I am intelligent and I can read and synthesize information quickly.
Please describe one of your favorite memories:
Current Relationships
my mother
Are you currently in a committed romantic relationship?
No
If YES, with whom and for how long?
Quality of relationship: (Positive / Mixed / Negative)
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?
If you are co-parenting with an ex-partner, any areas of concern or conflict?
Any relationship problems with other family members, (parents, siblings, etc.)?
No
Any conflict with others outside of family, (friends, coworkers, neighbors, etc.)?
No
To whom are you closest?
Physical, Family, Relationships, Work/School
Physical, Family, Relationships, Work/School
Mental Health Treatment History
Age at first mental health treatment:
6
Why did you seek/receive treatment?
I threatened suicide at age 6 but it wasn't taken seriously and my depression wasn't treated until I was 15.
Have you ever met with a therapist?
Yes
I have worked with a number of therapists over the past 25 years, I had a lot of depression, PTSD, and anxiety that I've been working on pretty diligently with therapists.
If you would like me to consult with your previous therapist, please provide therapist information and sign your consent here:
January 4, 2026 at 7:21:09 PM
Have you ever been hospitalized for a mental health condition?
Yes
If yes, please complete below:
2003
Two Rivers (Kansas City, MO)
PTSD/dissociation related to childhood sexual abuse
Have you taken psychiatric medication in the past?
Yes
If yes, please complete below:
effexor 75mg 2x/day
currently taking
bupropion 75mg 2x/day
currently taking
abilify 15 mg
currently taking
Any other psychiatric medication:
It took me a long time to settle on these medications to manage severe, recurrent depression. I've been taking the same medications for about 10 years now
Health Futures when I was binge eating (DBT)
Providers
Primary Care Physician
Gretchen Anderson
6235615252
01 2026
Signature
Consent to contact Primary care Dr.
Yes
January 4, 2026 at 7:21:10 PM
Psychiatric Provider
Joseph Aubrey
4809512888
01 2026
Signature
Consent to contact psychiatric provider?
Yes
January 4, 2026 at 7:21:10 PM
I have a bunch of specialists at Mayo related to ongoing health issues due to past bariatric surgery and a gynecologist and a hematologist
Current Medications
Medication list attached separately?
Any concerns or troubling Side Effects with your medications?
No
If yes, please describe:
Psychiatric Medication
Medication
Abilify
Dosage/Frequency
15mg
When prescribed
Side effects
01 2015
N/A
Effexor
75mg 2x/day
01 2015
N/A
Bupropion
75mg 2x/day
01 2015
N/A
Vyvanse
50mg
08 2025
N/A
Medical Medication
Medication
Calcitriol
Dosage/Frequency
.25mcg 2x/day
Hyzaar
50/12.5 mg 1x/day
When prescribed
01 2023
Side effects
01 2023
Levothyroxine
175 mcg
Daysee (BC Pill)
semaglutide
(compounded)
01 2023
Medical Status
How would you describe your overall health?
(Poor / Below average / Average / Above average / Excellent)
Below Average
Date of last complete physical exam:
01 2026
Please list any significant findings:
(I have a physical scheduled this week) new - intermittent vertigo, ongoing - sleep apnea, high blood pressure, obesity
Date of last dental exam:
01 2026
Please list any significant findings:
(I have an exam scheduled this week)
Has your life changed because of your health?
Are you currently undergoing medical treatment?
Yes
Yes
Current medical treatment
ongoing management of chronic conditions
Please list any major illnesses, events or accidents from your medical history:
Duodenal switch surgery, left and right total knee replacements, ORIF of my right hip due to femur break
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
Hypertension
Obesity, Osteoporosis, Thyroid Problems
Other please specify):
sleep apnea, malabsorption issues secondary to duodenal switch surgery
Trauma History
Please indicate if you have ever experienced any of the following:
Physical Sexual or Emotional Abuse, Corporal Punishment
Other (please specify):
I did not tell anyone
Lasting emotional 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?
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?
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?
N
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)?
Yes
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
Childhood and Family History
Phoenix AZ
mother and father
Were you adopted?
No
mother
Were there frequent family moves?
No
Parents:
(Married / Never married / Separated / Divorced)?
Divorced
Parental Relationship:
Variable, Distant
Abusive, Violent
Mother
Chicago
Did your mother work when you were a child?
Yes
comptroller
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?
Scottsdale, AZ
Are you in communication with her?
Yes
Relationship with your mother growing up:
(Positive / Mixed / Negative / Abusive)
Mixed
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)
Mixed
Father
Chicago
Did your father work when you were a child?
Yes
His occupation?
engineer
Was you father generally healthy while you were growing up?
Yes
Is your father still living?
No
If living, where does he currently live?
If deceased, please provide year of death:
2025
Are you in communication with him?
Relationship with father growing up:
(Positive / Mixed / Negative / Abusive)
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)
Mixed
Siblings
Please indicate your birth order:
(Oldest / Youngest / Somewhere in the middle)
Oldest
How many siblings?
3
Siblings names and ages:
Suzanne (48), Ryan (36), Michael (33)
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?
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?
No
What was your favorite thing to do as a child?
Read
During childhood, how did you cope with difficult situations?
I overachieved in school and read alot
Indicate quality and experience of childhood home life (check all that apply):
Stable
Negative
Abusive, Violent
Options
At what age did you leave home and why?
18, 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
Mixed
Middle/High School
Positive
College
Positive
Year of high school graduation:
1992
Did you experience any of the following at school?
Attention difficulties
Social difficulties
Relationship History
Age at first intimate relationship:
35
Any struggles with sexual orientation or sexual identity?
No
Are you currently in a long-term relationship?
No
If currently married, how old were you at the time of marriage?
How old was your spouse at the time of marriage?
Do you have children together?
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?
Family Mental Health
Alcohol Abuse, Anger Problems, Attentional Difficulties, Autism, Bipolar Disorder, Depression, Dementia, Eating Disorder
Learning Difficulties, Legal Problems, Narcissistic Personality, Substance Abuse, Suicide Attempts, Violent Behavior
Please indicate if any of the following mental health conditions are/were present or suspected in immediate or extended family:
father
father
sister
brother
both brothers
sister
father
sister
brother
uncles
father
father
aunt
father
Which family member(s) have negatively impacted you the most?
my aunt's husband sexually abused me from about 4-6. My father was physically abusive and scapegoated me throughout my childhood.
Please indicate how significantly you have been impacted:
(Not at all / somewhat / Quite a bit / Greatly)
Greatly
Strengths and Goals
What are your goals for treatment?
I want to work on my trauma and food issues and deal proactively with other life stressors
When did you last feel emotionally healthy?
currently I'm emotionally stable and not actively depressed or anxious
What are you wanting to change most about your life?
I have a pretty fraught relationship with hunger/food
How have you made it through difficult times before?
I have continually pursued mental health treatment to improve my functioning
What do you consider your strengths?
I'm intelligent and I am committed to improving my mental and physical health despite challenges
What experience have you enjoyed most over the past week?
Spending time with my dog
Please share a positive belief you have about yourself:
I'm smart and caring