Mental Health Assessment Preparation

Sample Symptom & Goal Summary

Your Name: [Insert your name]

Date of Birth: [Insert DOB]

Contact Info: [Phone/email if needed]

🧠 What I’m Struggling With:

I’ve been having a really hard time with my mental health. I feel overwhelmed and stuck, and I think I might be dealing with [anxiety, depression, trauma, or addiction — use the ones that apply]. I’ve also had problems with [prescription drug use / painkillers / opioids] and I want help stopping and finding a better way to cope. Some days are really hard — I feel [tired, anxious, hopeless, unmotivated, irritable — pick what fits], and it’s affecting my sleep, energy, and relationships.

🎯 What I Need Help With:

A full mental health assessment Someone to talk to regularly (therapist or counselor) Help managing cravings or substance use Medication support (if recommended) A safe plan to start healing — mentally, emotionally, and physically

⏰ Availability / Insurance Info:

I’m available [weekday mornings / evenings / flexible — say what works] I have [Medicaid / no insurance / private insurance — or unsure]

📄 How to Use This:

• Read it during your first phone call or intake

• Bring a printout or screenshot to your appointment

• Let them know your top priority (e.g., “I need help with addiction and depression”)

Would you like me to customize this with your specific symptoms, schedule, or situation? You can tell me anything you'd like included or left out — totally confidential here.

You said:

yes

Absolutely — I’ll help you customize your summary. Just answer a few questions below (you can skip anything you’re not ready to share), and I’ll build it for you:

👇 Please share what you're comfortable with:

1. What are you mainly struggling with right now?(e.g., depression, anxiety, trauma, drug use, sleep problems, mood swings)

2. Are you currently using prescription drugs, opioids, or anything else?(Only if you feel safe sharing — it helps tailor treatment needs)

3. How is this affecting your daily life?(e.g., trouble working, isolating from people, can’t sleep, feel hopeless)

4. What do you want most from treatment right now?(e.g., stop using, feel stable, talk to someone, get on medication, get a diagnosis)

5. Do you have insurance?(e.g., Medicaid, private insurance, no insurance, not sure)

6. When are you available for appointments?(e.g., mornings, evenings, any time)

7. Book mental health assessment