New Patient Evaluation

This questionnaire is designed to help Dr. Courtnee Pelton, Psy. D, understand more about you. The primary purpose of asking these questions is to develop a treatment plan that will best suit the reasons you are seeking assistance. By completing these questions as completely and honestly as you can, Dr. Pelton will be able to offer you treatment most in line with your reasons for coming to this clinic.

Hint: Use the 'tab' key to switch between fields without using the mouse.

Demographics: Please complete ALL information in this section.

Primary Concern

For example, relationships with family and friends, or your desire to have fun.

Please rate how often the following has occurred over the past 2 weeks:

S:

I:

G:

E:

C:

A:

P:

S:

Risk Assessment

e.g., writing goodbye letter, purchasing pills, obtaining a weapon

Mental Health History

Military History

Coping

Goals For Treatment

Please list 3 goals for treatment.

1.
2.
3.
Typing your full name will indicate your signature.