Assessment Form - Phillip Candland

Please complete this form with detailed answers. Your answers will be used to assist the therapist in developing an accurate treatment plan.

Your detailed answers will also be used in obtaining the best possible coverage from your insurance provider if such treatment is covered under your medical health insurance policy.

Failure to provide detailed answers will only hurt the development of an accurate treatment plan and delay or prevent the payment of your health insurance benefits (if any).

  • Dates of TreatmentName of ProviderProvider AddressProvider Phone NumberReason for Treatment/Diagnosis 
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  • NamePhysician TypePhone NumberSpecialty 
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  • Name of MedicationDosageFrequency TakenTime Period Medication Was TakenReason for Medication 
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  • Name of MedicationDosageFrequency TakenWhen was Medication PrescribedReason for Medication 
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  • 1. PARTICIPATING CRISIS

  • 2. FAMILY HISTORY

  • 3. CHILD DEVELOPMENT

  • 4. SUBSTANCE USE HISTORY

  • 5. SOCIO-ECONOMIC

  • 6. PSYCHIATRIC AND MENTAL HEALTH

  • 7. MEDICAL HISTORY

  • 8. VIOLENT BEHAVIORS HE HAS EXHIBITED VERBAL OR PHYSICAL

  • 9. SUICIDAL IDEATION

  • 10. EXPOSURE TO TRAUMA