Group Assessment Form

Bob Bennett, MD,CGP,FAPA · Melissa Black, PhD,CGP
Dale C. Godby, PhD,CGP,ABPP · Myrna Little, PhD,CGP
Scott Nelson, PhD, CGP

6330 LBJ Fwy, Suite 150, Dallas, TX 75240
972-392-4155

Group Assessment Form

Group Therapist		Day	Time
Patient Name
Home Phone		OK to leave message? Yes No
Work Phone		OK to leave message? Yes No

Age	DOB	Occupation
Marital Status		Religion
Intelligence		Ethnicity

Social Background

Education

CAN ATTEND:
Morning		Not before
Lunch		Between
Evening		Not before

Referred By
On	Letter or Contact
Initial Interview With
On	Letter or Contact
Motivation:
Capacity for Insight:
Personality Resources:

Agreed Fee

Once/Twice Weekly

Group Agreement

Yes

No

Began Group Treatment
Ended Group Treatment
Result
Reason for Leaving
Letter to Referrer

PRESENTING SYMPTOMS

PERSONALITY AND INITIAL CONTACT

DYNAMIC FORMULATION

PREVIOUS TREATMENT

FAMILY HISTORY

RELEVANT INFORMATION