Initial Psych Eval

client is a [text name="age" default="Enter Age"] year old [select name="ethnicity" value="Caucasian|African American|Hispanic|Asian"][select name="gender" value=" male| female| choice C"] with h/o [checkbox name="variable_1" value="Depression|Anxiety|Opioid abuse, in remission|Cocaine abuse, in remission|Alcohol abuse, in remission | Bipolar disorder |Adjustment disorder | PTSD | Schizoaffective disorder| Schizophrenia "]. Reports to have been attending CAP for [text name="variable_3" default="sample text"], [select name="variable_1" value="self referred|referred by"] [text name="variable_1" default="sample text"]. client presents as stable at this time and is considered to be an accurate historian. reports first entered into psychiatric care at age [text name="variable_4" default="sample text"]. Currently endorses following symptoms:[checkbox name="variable_2" value="low mood|anhedonia|guilt|worthlessness| hopelessness|regret|decreased appetite| increased appetite|psychomotor retardation|suicidality|anxiety|aggressive behavior|impulsivity|difficulty with focus/ attention|irritability|panic attacks| agoraphobia| decreased need for sleep|obssessive-compulsive behaviors| |withdrawn|difficulty sleeping|auditory hallucinations|visual hallucinations|thought broadcasting|thought insertion"]

[checkbox name="variable_1" value="reports feeling stable on current medication regimen"]
[checkbox name="variable_2" value="with no reported side effects"]
Reports sleep is [select name="variable_5" value="Good|Fair|Poor|Terrible|Not discussed"]; (averages [text name="hours" default="sample text"]hours per night)
appetite is [select name="variable_6" value="Good|Fair|Poor|Terrible|Not discussed"]; 
energy levels are [select name="variable_7" value="Good|Fair|Poor|Terrible|Not discussed"][text name="other" default="sample text"]; 
concentration is [select name="variable_8" value="Good|Fair|Poor|Terrible|Not discussed"]. denies symptoms of mania/hypomania. denies past or current eating disorder. denies auditory or visual hallucinations. denies history of psychosis.  denies symptoms of PTSD. denies SI/HI. denies safety concerns  

Past/Family/Social History* 
Social Supports:[checkbox value="none|significant other|extended family|children|friends|church members"]. Marital status: [select value="married|partnered|single|"][textarea rows="1"].Children: 
[select value="0|1|2|3|4|5|6|7|"][textarea rows="1"].Lives: 
[select value="with significant other|alone|with children|with extended family|with parents|"][textarea rows="1"]. Works: [select value="on disability|retired|unemployed|works as a |"][textarea rows="1"].Financial Concerns:[select value="none|related to healthcare costs|related to supporting family|"][textarea rows="1"].Source of Income: [select value="disability|social security|unemployment|work|family support|"][textarea rows="1"].Housing Concerns:[select value="none|unstable housing situation related to |"][textarea rows="1"]. Spirituality:[select value="Christian|Catholic|Muslim|Jewish|Spiritual but not practicing|Athiest|Agnostic|"].Sexual Orientation:[select value="heterosexual|homosexual|bisexual|declined to answer|unable to assess due to symptomatic presentation|"]. Military:[select value="denied|retired |active |"][textarea rows="1"]. Legal Concerns:[select value="denied|"][textarea rows="1"]