Self-Pay Assessment Step 1 of 8 12% Self-Pay AssessmentStill Waters Professional Counseling Services, Inc. 3711 Executive Center Dr. Augusta, GA 30907Date of Self-Pay Assessment MM slash DD slash YYYY Location of Service: Home Office Telehealth Other Individual's Information"Individual" refers to the person receiving the assessment.Name (Individual) First Middle Last Suffix Date of Birth (Individual) Month Day Year Legal Status (Individual)Check all that apply. Individual is of legal age of consent Individual is under aged (18) Individual is under the care of a custodial parent or legal guardian Gender (Indvidual) Male Female Transgender Unknown Other Marital Status (Individual) Common Law Married Separated Widowed Divorced Single N/A Individual's Contact InformationAddress (Individual) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone (Individual)Email (Individual) Emergency ContactName (Emergency Contact) First Last Suffix Phone (Emergency Contact) Individual's Presenting Problems and Requested ServicesWhat is/are the Individual's presenting problem(s) and requested services?Why are they here? (In client's own words when possible.) Individual's and Family's InformationFamily/Social Supports (Individual and Family)Include current and historical information:Spiritual and/or Cultural Variables (Individual and Family)Include current and historical information:Education/Vocation (Individual and Family)Include current and historical information: Document if compliant with currently prescribed medications. Psychiatric & Medical Current/History (Individual & Family)A brief psychiatric and medical current status and history indicating the individual's baseline family structure including familial and psychiatric pathology and relationship with parent's, spouse, and children.Psychiatric (Individual and Family)Include current and historical information:Physical/Sexual/Emotional Abuse (Individual and Family)Include current and historical information:Substance Abuse (Individual and Family)Include current and historical information:Medical and Medications (Individual and Family)Include current and historical information: Document if compliant with currently prescribed medications. SNAPS (Strengths, Needs, Abilities, Preferences)Strengths:Needs:Abilities:Preferences: Summary of Findings/Formulation and Recommendations:Findings/RecommendationsIdentify problem areas and underlying dynamics. Include information used to make differential diagnosis and make recomendations.Name (Assessor)* First Last License Signature (Assessor)*Email (Assessor)* Enter Email Confirm Email Signature Date (Assessor)* MM slash DD slash YYYY Δ
