Adult Client Screening Questionnaire

Adult Client Screening Questionnaire · Carla E. Marin, PhD

What this form is for

Please complete this form so we can determine whether this practice is a good fit for your needs before scheduling an initial appointment.

How to complete this form

Complete everything below on your phone or computer. When you are done, tap “Save as PDF” at the bottom and then email the file to Dr. Marin at carlamarinphd@gmail.com.

Nothing you type here is sent or saved anywhere until you send the file yourself. If you close or reload this page before saving, your answers will be deleted. It takes about five minutes. Blanks are fine.

Your information

Initials only at this stage. Full details are collected later, on the intake form.

Your initials

Date of birth

Best contact phone

College student information

If this applies to you.

Are you currently a college student?

Yes No

School name

Year in school

Mental health treatment history

Have you previously received therapy or counseling?

Yes No

Have you previously seen a psychiatrist or prescriber?

Yes No

Have you previously been hospitalized or received a higher level of psychiatric care (for example, partial hospitalization or intensive outpatient)?

Yes No

Are you currently taking any psychiatric medication(s)?

Yes No

If currently or previously on psychiatric medication, please list it here

Past diagnoses, treatment providers, and if treatment was helpful

Most pressing concerns right now

What is bringing you to seek services at this time? Please describe your top concern(s).

Current symptoms and functioning

For each area below, mark the number that best reflects your functioning over the past two to four weeks.

0 Not a problem · 1 Mild or occasional · 2 Moderate or frequent · 3 Severe or almost constant

Area	0	1	2	3
Anxiety, fears, or worry
Intrusive or unwanted thoughts
Low mood or sadness
Impulsivity, hyperactivity, or inattentiveness
Irritability or anger
Repetitive or compulsive behaviors
Sleep difficulties
Academic or work difficulties
Relationship or social difficulties
Alcohol, cannabis, or other substance use getting in the way

Your strengths and supports

Every person has strengths. Please share what you are noticing that is going well for you right now: skills, interests, supports, recent progress, anything else.

Your answers are used only to help us decide whether this practice can meet your needs. This is not a diagnostic tool and nothing here is a diagnosis. If you are in crisis or having thoughts of self-harm, please call or text 988 (Suicide and Crisis Lifeline) or call 911.