physiotherapy | awsten knight

10: psychological evalution

please keep in mind that this is a work of fiction, the answers to this were given by me to fit the storyline.

TW: explicit description of mental health problems, suicidal behaviour, ADHD

PSYCHOLOGICAL EVALUATION QUESTIONNAIRE

The purpose of this questionnaire is to obtain a comprehensive picture of your background. During a later interview you will have an opportunity to discuss these concerns in more detail, if necessary. You will need to have this form completed prior to your scheduled interview.

Name: Awsten Knight
Date: Nov 17th, 2017
Age: 25
DOB: Jan 17th, 1992

FAMILY OR SOCIAL HISTORY:
Where were you born? What other places did you live and for how long did you live there?:

Cypress, Texas
20 years

Houston, Texas
5 years

Please check the following words you would use to describe yourself.

✖️ Intelligent
✖️ Sensitive
✖️ Full of Regrets
_____ Crazy
✖️ Considerate
_____ Confused
_____ Attractive
_____ Suicidal (in the past)
✖️ Good sense of humor
_____ Confident
✖️ Loyal
_____ Worthless
_____ Deviant
_____ Unlovable
✖️ Hardworking
_____ Persevering
✖️ Can't Make a Decision
_____Worthwhile
✖️Trustworthy
_____ A Nobody
_____Unattractive
✖️ Inadequate
____ Incompetent
_____ In Conflict
_____ Memory Problems
✖️ Ambitious
____ Evil
____ Useless
____ Ugly
✖️ Naïve
_____ Stupid
✖️ Honest

Siblings:
Number of brothers
0
Brothers ages
____________________

Number of sisters
1
Sisters ages
21

Number of step or half siblings, gender, and ages
____________________________

Father:
If alive, give father's present age
58
Occupation: Nurse
Health: good

What is/was your relationship like?
caring, supportive

as a child?
tried to be supportive of me, but I used to not like him (I had issues with authority as a kid), used to mouth off on him a lot for no reason

as an adult?
proud of my occupation, talk to him regularly

Mother:
If alive, give mother's present age
54
Occupation: Gym Teacher
Health: good

What is/was your relationship like?
nurturing, loving

as a child?
very invested, had me try out different things, protective

as an adult?
caring, loving, proud of me

Please check any of the following that apply to your childhood or adolescence.

✖️ Unhappy Childhood
✖️ Emotional/Behavioral Problems
✖️ Medical Problems
_____ Sexual Abuse
_____ Family Problems
_____ Alcohol Abuse
_____ Legal Problems
_____ Emotional Abuse
✖️ School Problems
_____ Drug Abuse
_____ Physical Abuse
_____ Other _________