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Psychological Assessment Form Template

Create effective psychological assessments easily

If you're a mental health professional struggling to capture accurate insights into your clients' psychological well-being, this psychological assessment form template is designed for you. It helps you systematically evaluate mental health conditions, track treatment progress, and enhance communication with clients. You'll benefit from its user-friendly design, customizable fields, and the ability to generate insightful reports, all while ensuring compliance with WCAG-aligned standards. Dive into this template and streamline your assessment process effortlessly.

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Full name
Date of birth
Email address
Mobile phone
Preferred contact method
Email
Phone call
Text message
No preference
Emergency contact name
Emergency contact phone
Relationship to you (emergency contact)
Parent/Guardian
Spouse/Partner
Family member
Friend
Other
Please Specify:
Type your full name as your electronic signature
Signature date
Do you consent to participate in psychological assessment and treatment?
Yes
No
Age range
Under 18
18-24
25-34
35-44
45-54
55-64
65+
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
If you prefer to self-describe your gender, please specify
Pronouns
She/her
He/him
They/them
Prefer to self-describe
Prefer not to say
If you prefer to self-describe your pronouns, please specify
Relationship status
Single
In a relationship
Married/Partnered
Separated/Divorced
Widowed
Prefer not to say
Current living situation
Live alone
With partner/family
Shared housing
Residential facility
Unhoused/Temporary
Prefer not to say
Employment/School status
Employed full-time
Employed part-time
Self-employed
Unemployed
Student
Retired
Unable to work
Prefer not to say
Primary concern you want help with
Briefly describe your main concern
How long has this been a significant concern?
Less than 2 weeks
2-8 weeks
2-6 months
6-12 months
More than 1 year
Not sure
How much is this affecting your daily functioning?
Not at all
A little
Moderately
Quite a bit
Extremely
Little interest or pleasure in doing things
Never
Rarely
Sometimes
Often
Always
Feeling down, depressed, or hopeless
Never
Rarely
Sometimes
Often
Always
Feeling nervous, anxious, or on edge
Never
Rarely
Sometimes
Often
Always
Uncontrollable worry
Never
Rarely
Sometimes
Often
Always
Panic or sudden surges of fear
Never
Rarely
Sometimes
Often
Always
Trouble falling or staying asleep, or sleeping too much
Never
Rarely
Sometimes
Often
Always
Difficulty concentrating
Never
Rarely
Sometimes
Often
Always
Irritability or anger outbursts
Never
Rarely
Sometimes
Often
Always
Thoughts of self-harm or suicide (past month)
Yes
No
If you had self-harm or suicidal thoughts, please describe any plans, means, or supports you have
Do you feel safe today?
Yes
No
Substance use (any alcohol or drugs) in the past month
None
1-3 times this month
Weekly
Several times per week
Daily
On a typical day when you drink alcohol, how many drinks do you have?
None
1-2
3-4
5-6
7 or more
Prefer not to say
Have you ever been diagnosed with a mental health condition?
Yes
No
If yes, please list prior diagnoses and approximate dates
Have you had counseling or therapy before?
Yes
No
If yes, when was your most recent therapy and what was helpful or unhelpful?
Are you currently taking any prescription or over-the-counter medications or supplements?
Yes
No
If yes, please list names, doses, and purpose
Do you have any significant medical conditions or allergies?
Yes
No
If yes, please describe your medical conditions or allergies
If yes, please describe relevant family history
Family history of mental health or substance use conditions
Yes
No
Overall stress level
Low
Moderate
High
Very high
Not sure
Work or school stress
Low
Moderate
High
Very high
Not applicable
Satisfaction with social support
Very dissatisfied
Dissatisfied
Neutral
Satisfied
Very satisfied
Physical activity frequency
Never
Rarely
Sometimes
Often
Always
Any accommodations or accessibility needs for sessions?
Caffeine intake
None
Low (about 1 per day)
Moderate (2-3 per day)
High (4+ per day)
Prefer not to say
What are your goals for therapy? (select all that apply)
Please describe your top priority goal in your own words
Preferred therapy format
In-person
Video/online
Phone
No preference
Preferred appointment times
Weekday mornings
Weekday afternoons
Weekday evenings
Weekends
No preference
I am open to trying structured, skills-based approaches (e.g., CBT) if recommended
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
How likely are you to complete brief between-session practice if suggested?
0 Not at all likely
1
2
3
4
5 Extremely likely
Do you consent to coordinate care with your primary care provider (PCP)?
Yes
No
Primary care provider name
Primary care provider phone
I have reviewed the Notice of Privacy Practices (HIPAA) and agree
Yes
No
Type your full name to confirm the above consents
Date
Communication preferences for reminders
Email reminders
SMS/text reminders
Voicemail messages
No reminders
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Paper art illustration depicting a psychological assessment form for FormCreatorAI article

When to use this form

This form is useful when you need a structured intake or check-in for therapy, counseling, school support, or occupational health. Use it at first contact to capture presenting concerns, risks, and how daily life is affected; during treatment to monitor change; or when triaging waitlist referrals. Private practices, campus services, and EAP coordinators can adapt it for brief screenings or return-to-work planning. Researchers can standardize baseline and follow-up data across participants. To gather broader background details, pair it with the Psychology questionnaire form. If mood is a key focus, add the Beck depression inventory questionnaire form to track symptom severity over time and inform care decisions.

Must Ask Psychological Assessment Questions

  1. What is the primary concern you want help with today?

    This focuses the assessment and sets clear goals in your words. It helps route your case to the right provider and flags urgent needs fast.

  2. When did these concerns start, and what events or triggers seem related?

    Onset and triggers reveal patterns that inform diagnosis and timing. They guide decisions on stabilization versus longer-term treatment.

  3. How are your symptoms affecting daily functioning (work or school, relationships, sleep, appetite)?

    Functional impact shows severity and helps prioritize interventions. It also provides baseline measures for progress reviews.

  4. What supports or coping strategies do you use, and which ones help most?

    This identifies strengths you can build on and avoids repeating what has not worked. For a simple strengths practice to track between sessions, consider the Daily gratitude journal form.

  5. Are you experiencing thoughts of harming yourself or others, or any immediate safety concerns?

    Safety screening ensures urgent risks are addressed and documented. Clear answers trigger the right escalation steps and referral pathways.

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