Sample Assessment Forms
DIAGNOSTIC ASSESSMENT REPORT
Name ______________________________________ Therapist __________________
Intake/Assessment Date(s) _____________________ Report Date ________________
1. Purpose of Visit/Current Life Situation (Include duration/frequency of symptoms)
2. History of Current Problem/Development Incidents/Treatment History/Medications,
etc.
3. Current Functioning, Symptoms, and Impairments (e.g., occupational, social,
emotional)
STRENGTHS _______________________________________________________
WEAKNESSES ______________________________________________________
4. Family Mental Health History
5. Other (Substance abuse, suicidal ideations, court referral, etc.)