For appointments arranged via your doctor or as part of a legal, therapeutic, or trauma recovery process
1. 🧾 Basic Details
- Name:
- Date of Appointment:
- Location / Clinic:
- Practitioner’s Name (if known):
- Referred by (Doctor, Legal, Other):
2. 🧠 What You’re Seeking Help For
Use this section to briefly describe why you’re attending this assessment.
You don’t need to go into deep detail — just a clear summary.
Example prompts:
- “I’m here because I’ve experienced emotional and psychological abuse for several years.”
- “This is part of my legal process after escaping a violent relationship.”
- “I’m dealing with PTSD symptoms following long-term domestic violence.”
- “I was referred because I’m struggling with anxiety, trust issues, and flashbacks.”
My reason for attending:
3. 💔 History You Feel Comfortable Sharing
Check off what you may be ready to talk about:
☐ Emotional abuse
☐ Physical abuse
☐ Coercive control
☐ Sexual abuse
☐ Financial abuse
☐ Isolation or manipulation
☐ Witnessing abuse
☐ Childhood trauma
☐ Recent major stressors (grief, divorce, stalking, threats)
☐ Living in fear or constant hypervigilance
You can say:
“There is more I’m not ready to talk about today.”
“I’ve written a timeline to help me explain what I’ve been through.”
“I can talk about the symptoms, even if I’m not ready to talk about the details yet.”
4. 🧠 Mental Health Symptoms You’re Experiencing
Choose any that apply or write your own:
☐ Panic attacks
☐ Flashbacks
☐ Nightmares
☐ Sleep disturbances
☐ Hypervigilance / Jumpiness
☐ Difficulty concentrating
☐ Memory issues
☐ Numbness or dissociation
☐ Guilt or shame
☐ Emotional overwhelm
☐ Fear of people or places
☐ Mood swings or emotional dysregulation
☐ Difficulty trusting people
☐ Low self-worth
☐ Intrusive thoughts
☐ Isolation / withdrawal
Additional notes or examples:
5. 🗂️ Things That Might Help the Assessor Understand
You may want to bring or mention:
☐ Police reports or reference numbers
☐ Notes or timeline of events
☐ Emails or messages (printouts or screenshots)
☐ Legal documents (protective orders, custody papers)
☐ Medication list
☐ Therapist letter or past assessments (if applicable)
☐ List of incidents or symptoms
☐ Safe contact person to verify your situation
6. 🛑 Boundaries and Consent
You have the right to:
✅ Pause or stop the session if you feel overwhelmed
✅ Refuse to answer certain questions
✅ Ask how your information will be used
✅ Request a copy of the report
✅ Ask for breaks or emotional support
Boundaries I’d like to express today:
7. 💌 A Letter to Yourself (Optional)
A short note to remind yourself why you’re doing this, and how far you’ve already come.
“I’m doing this because…“
“I want to feel safe again…”
“I know my story matters, and this is part of reclaiming it.”
Write a few words here, just for you:
8. 📞 Emergency / Support Contacts
- My doctor:
- My lawyer (if applicable):
- A trusted friend:
- Local domestic abuse helpline:
- Mental health crisis line:
