Adult Mood, Anxiety, and Depression History Form

General Details

First Name

Last Name

Date of birth

Gender

Contact Details

Phone *

Email *

Additional Information

Occupation/School Status (if applicable)

Presenting Concerns

What are your main concerns regarding your mood, anxiety, or depression?

When did you first start experiencing these symptoms?

Related to mood, anxiety and/or depression

Have your symptoms worsened, improved, or remained the same over time?

What triggers or situations make your symptoms worse?

What helps you feel better, even temporarily?

Mood History

How would you describe your mood in the past two weeks? (e.g., low, irritable, fluctuating, stable)

Do you experience sudden mood swings?

Have you ever had a period where you felt unusually high-energy, restless, or overconfident?

Do you feel emotionally numb or disconnected from others?

Have you lost interest in activities you used to enjoy?

Anxiety History

Do you often feel anxious, restless, or on edge?

Do you experience physical symptoms when anxious (e.g., rapid heartbeat, sweating, nausea, shaking)?

Do you have persistent worries that interfere with daily life?

Do you avoid certain situations due to fear or anxiety?

Have you ever experienced a panic attack?

Depression History

Do you often feel sad, hopeless, or empty?

Have you experienced changes in appetite or weight?

Do you feel fatigued or lack motivation most days?

Do you struggle with concentration or memory issues?

Have you had thoughts of self-harm or suicide?

If yes to the above question - please provide some more information here

1. Have you ever acted on these thoughts, 2. Do you have a safety plan in place?

Sleep & Energy Levels

How many hours do you sleep per night?

Do you have trouble falling or staying asleep?

Do you feel rested upon waking?

Do you feel fatigued or sluggish throughout the day?

Have you noticed unusual sleep patterns (e.g., nightmares, early waking, excessive sleeping)?

Coping & Emotional Regulation

How do you typically cope with stress? (e.g., talking to friends, avoidance, self-care, unhealthy coping mechanisms)

Do you have a strong support system (family, friends, therapist, etc.)?

Have you ever engaged in self-harm (e.g., cutting, burning, scratching)?

Do you feel you can control your emotions, or do they overwhelm you?

Have you ever been diagnosed with a mood or anxiety disorder in the past?

If yes, please specify

Past & Current Treatments

Have you received treatment for mental health concerns before?

If yes, please specify

Have you taken any medication for mood, depression, or anxiety?

If yes, please list the medications, including frequency and dosage

Have you ever been hospitalized for mental health concerns

Have you tried therapy or counseling before?

If yes, please provide information on the type you had and how you found it

Are you currently using any natural remedies (e.g., supplements, herbal remedies, hypnotherapy)?

Please list any current natural remedies

Risk Factors & Lifestyle

Do you have a family history of mental health conditions?

Please provide details

Do you use substances (alcohol, drugs, caffeine) to manage mood or anxiety?

If yes, please note the substances you use and the frequency (e.g., daily, once a week etc.)

Have you experienced any major life events or trauma that may be affecting your mental health?

How would you rate your current stress levels?

Do you feel safe at home, work, or school?

Goals & Next Steps

What are your main goals for seeking support?

What kind of treatment or support do you feel would help you the most?

Is there anything else you’d like your assessor to know about your mental health?

Thank you for completing this form. Your responses will help us create a tailored support plan to address your needs.