Emotional Evaluation for Trauma

New Paradigm

Tell Us What You Are Experiencing

This confidential evaluation is designed to help us understand what you are currently experiencing and how heavily it may be affecting your emotional well-being. Please answer as honestly as you can. Your responses help us review your situation carefully and recommend the most appropriate next step for support.

Full Name

Address

City

Country

Phone Number

Email Address

Age

Gender

Seeking Treatment For Briefly describe what you would like support with. All information is strictly confidential.

Current Medication Use & Dosage Please list any medications you are currently taking, including dosage. Write "None" if not applicable.

Psychiatric Diagnosis If you have been diagnosed with a psychiatric condition, list it here. Write "No" if not applicable.

Psychiatric Hospital Admission Have you spent time in a psychiatric hospital?

Yes No

Self-Assessment

Tick each statement that reflects how you have been feeling recently.

Your information is treated confidentially and used only to review your situation and prepare the appropriate next step.