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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 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
Eleanor511
* Required
12 12 1990
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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):
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?
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?
If yes, what are they?
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Specify which areas of your life are affected by this problem:
Relationships
Other?
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Stressful Life Events
Please indicate if any of the following have occurred within the past 12 months:
Pregnancy
Financial Stress
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. Feeling down, depressed, or hopeless?
3. Feeling more irritated, grouchy, or more angry than usual?
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?
6. Feeling nervous, anxious, frightened, worried, or on edge?
7. Feeling panic or being frightened?
8. Avoiding situations that make you anxious?
9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs?)
10. Feeling that your illnesses are not being taken seriously enough?
11. Thoughts of actually hurting yourself?
12. Hearing things other people couldn't hear, such as voices even when no one was around?
13. Feeling that someone could hear your thoughts, or that you could hear what another person was thinking?
14. Problems with sleep that affected your sleep quality overall?
15. Problems with memory (e.g., learning new information) or with location (e.g., finding your way home?
16. Unpleasant thoughts, urges, or images that repeatedly enter your mind?
17. Feeling driven to perform certain behaviors or mental acts over and over again?
18. Feeling detached or distant from yourself, your body, your physical surroundings, or your memories?
19. Not knowing who you really are or what you want out of life?
20. Not feeling close to other people or enjoying your relationship with them?
21. Drinking at least 4 drinks of any kind of alcohol in a single day?
22. Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco?
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)]?
Current Status
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Are you currently attending school?
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Have you ever been terminated from a job?
Are you currently receiving disability?
Are you an active member of the Armed Forces?
Have you ever served in the military?
Were you ever in combat?
Do you have an illness or injury related to your service
Family, Friends
Are you satisfied with your home and family life?
How socially active are you?
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
Are you physically active? Yes / Sometimes / No
Current satisfaction with lifestyle, hobbies, activities:
High / Medium / Low
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?
If YES, with whom and for how long?
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Quality of relationship: (Positive / Mixed / Negative)
Any current romantic relationship conflicts?
Are you concerned about any potential violence?
Any recent breakups?
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.)?
Any conflict with others outside of family, (friends, coworkers, neighbors, etc.)?
To whom are you closest?
Relationships
Relationships
Mental Health Treatment History
Age at first mental health treatment:
Why did you seek/receive treatment?
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Have you ever met with a therapist?
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If you would like me to consult with your previous therapist, please provide therapist information and sign your consent here:
October 8, 2025 at 8:05:30 PM
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Have you ever been hospitalized for a mental health condition?
If yes, please complete below:
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Have you taken psychiatric medication in the past?
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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Signature
Consent to contact Primary care Dr.
October 8, 2025 at 8:05:31 PM
Psychiatric Provider
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Signature
Consent to contact psychiatric provider?
October 8, 2025 at 8:05:31 PM
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Current Medications
Medication list attached separately?
Any concerns or troubling Side Effects with your medications?
If yes, please describe:
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Psychiatric Medication
Medication
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Dosage/Frequency
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When prescribed
Side effects
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Medical Medication
Medication
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Dosage/Frequency
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When prescribed
Side effects
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Medical Status
How would you describe your overall health?
(Poor / Below average / Average / Above average / Excellent)
Date of last complete physical exam:
Please list any significant findings:
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Date of last dental exam:
Please list any significant findings:
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Has your life changed because of your health?
Are you currently undergoing medical treatment?
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?
Do you regularly take pain medication?
Please indicate personal concerns with any of the following physical symptoms:
Alzheimer’s Disease
Gastrointestinal Issues
Muscle Cramps
Other please specify):
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Trauma History
Please indicate if you have ever experienced any of the following:
Medical Trauma
Discrimination
Homelessness
Other (please specify):
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Unsupportive
Lasting emotional symptoms
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?
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?
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?
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?
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?
6
Were your parents ever separated or divorced?
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?
8
Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
9
Was a household member depressed or mentally ill or did a household member attempt suicide?
10
Did a household member go to prison?
Mental Health History
Have you ever intentionally harmed yourself or seriously thought about doing so?
Have you suffered racial, sexual, or other forms of discrimination?
Do you have a history of alcohol or substance abuse?
Do you have a history of an eating disorder (restricting, binging, purging)?
Any history of gambling, shopping, sexual, or other behavioral addictions?
Do you have a history of unstable relationships?
Have you frequently changed jobs?
Have you ever had problems with your temper or violence?
Have you ever been convicted of a misdemeanor or felony?
Childhood and Family History
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Were you adopted?
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Were there frequent family moves?
Parents:
(Married / Never married / Separated / Divorced)?
Parental Relationship:
Close
Negative
Violent
Mother
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Did your mother work when you were a child?
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Was you mother generally healthy while you were growing up?
Is your mother still living?
If deceased, please provide year of death:
If living, where does she currently live?
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Are you in communication with her?
Relationship with your mother growing up:
(Positive / Mixed / Negative / Abusive)
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
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Did your father work when you were a child?
His occupation?
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Was you father generally healthy while you were growing up?
Is your father still living?
If living, where does he currently live?
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If deceased, please provide year of death:
Are you in communication with him?
Relationship with father growing up:
(Positive / Mixed / Negative / Abusive)
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
Please indicate your birth order:
(Oldest / Youngest / Somewhere in the middle)
How many siblings?
Siblings names and ages:
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Are you in communication with some/all of them?
Do you have any family members living in the area?
Any problems with your delivery and birth?
Any developmental delays?
Childhood medical problems?
Any childhood hospitalizations or intense medical/dental procedures?
Did you have a favorite pet growing up?
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):
Variable
Chaotic
Abusive
Arrests
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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Please indicate your school experience:
(Positive / Negative / Mixed)
Elementary School
Middle/High School
College
Year of high school graduation:
Did you experience any of the following at school?
Relationship History
Age at first intimate relationship:
Any struggles with sexual orientation or sexual identity?
Are you currently in a long-term relationship?
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:
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Did you have children together?
Family Mental Health
Please indicate if any of the following mental health conditions are/were present or suspected in immediate or extended family:
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)
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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