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<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<title>Therapy Questionnaire</title>
</head>
<body>
<h2>Client Information</h2>
<form action="#" method="post">
<!-- Personal Information -->
<label for="name">Name:</label>
<input type="text" id="name" name="name" required>
<label for="address">Address:</label>
<input type="text" id="address" name="address" required>
<label for="dob">DOB:</label>
<input type="date" id="dob" name="dob" required>
<label for="age">Age:</label>
<input type="number" id="age" name="age" required>
<label for="phone">Phone Number(s):</label>
<input type="tel" id="phone" name="phone" required>
<label for="sex">Sex:</label>
<select id="sex" name="sex" required>
<option value="male">Male</option>
<option value="female">Female</option>
<option value="other">Other</option>
</select>
<label for="ethnicity">Ethnicity:</label>
<input type="text" id="ethnicity" name="ethnicity" required>
<label for="maritalStatus">Marital Status:</label>
<select id="maritalStatus" name="maritalStatus" required>
<option value="single">Single</option>
<option value="married">Married</option>
<option value="divorced">Divorced</option>
<option value="widowed">Widowed</option>
</select>
<label for="referralSource">Referral Source:</label>
<input type="text" id="referralSource" name="referralSource" required>
<label for="todayDate">Today’s Date:</label>
<input type="date" id="todayDate" name="todayDate" required>
<!-- Presenting Concerns -->
<h2>Presenting Concerns</h2>
<label for="reasonForReferral">Reason for Referral:</label>
<textarea id="reasonForReferral" name="reasonForReferral" rows="4" required></textarea>
<!-- Add other fields as needed -->
<input type="submit" value="Submit">
</form>
</body>
</html>
<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<title>Client Questionnaire</title>
</head>
<body>
<h1>Client Questionnaire</h1>
<!-- Personal Information Section -->
<h2>Personal Information</h2>
<form>
<label for="name">Name:</label>
<input type="text" id="name" name="name">
<label for="address">Address:</label>
<input type="text" id="address" name="address">
<!-- Add more fields for Date of Birth, Age, Phone Number(s), etc. -->
<label for="sex">Sex:</label>
<select id="sex" name="sex">
<option value="male">Male</option>
<option value="female">Female</option>
<option value="other">Other</option>
</select>
<!-- Add more fields for Ethnicity, Marital Status, Referral Source, Today’s Date, etc. -->
</form>
<!-- Presenting Concerns Section -->
<h2>Presenting Concerns</h2>
<form>
<label for="reasonForReferral">Reason for Referral:</label>
<textarea id="reasonForReferral" name="reasonForReferral"></textarea>
<!-- Add more fields for symptoms, duration, and their impact on functioning -->
</form>
<!-- Social History Section -->
<h2>Social History</h2>
<form>
<!-- Add fields for family relationships, children, siblings and parents' relationships, family mental health, etc. -->
</form>
<!-- Social Supports Section -->
<h2>Social Supports</h2>
<form>
<!-- Add fields for friendships, meaningful activities, religion/spirituality, community supports, etc. -->
</form>
<!-- Legal History Section -->
<h2>Legal History</h2>
<form>
<!-- Add fields for legal guardian, criminal history, etc. -->
</form>
<!-- Education Section -->
<h2>Education</h2>
<form>
<!-- Add fields for highest grade completed, major, special education, current school status, etc. -->
</form>
<!-- Employment Section -->
<h2>Employment</h2>
<form>
<!-- Add fields for employment status, hours per week, reason for unemployment, etc. -->
</form>
<!-- Military Section -->
<h2>Military</h2>
<form>
<!-- Add fields for military service history -->
</form>
<!-- Trauma Section -->
<h2>Trauma</h2>
<form>
<!-- Add fields for various types of trauma, symptoms, etc. -->
</form>
<!-- Suicidal/Homicidal Ideation Section -->
<h2>Suicidal/Homicidal Ideation</h2>
<form>
<!-- Add fields for thoughts about dying, thoughts about suicide, previous attempts, etc. -->
</form>
<!-- Past Risk and Alerts Section -->
<h2>Past Risk and Alerts</h2>
<form>
<!-- Add fields for self-harm, losses, anniversary reactions, imminent stressors, etc. -->
</form>
<!-- Psychotropic Medications Section -->
<h2>Psychotropic Medications</h2>
<form>
<!-- Add fields for mood, anxiety, hallucinations, etc. -->
</form>
<!-- Strengths/Interests/Community Involvement Section -->
<h2>Strengths/Interests/Community Involvement</h2>
<form>
<!-- Add fields for life goals, strengths, abilities, etc. -->
</form>
<!-- Mental Status Exam Section -->
<h2>Mental Status Exam</h2>
<form>
<!-- Add fields for appearance, attitude, mood, affect, speech, thought process, etc. -->
</form>
<!-- Preliminary DSM V Diagnosis Section -->
<h2>Preliminary DSM V Diagnosis</h2>
<form>
<!-- Add fields for Axis I diagnosis -->
</form>
<!-- Referrals Made Section -->
<h2>Referrals Made</h2>
<form>
<!-- Add fields for psychiatric, substance use, medical, other referrals -->
</form>
</body>
</html>
<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<title>Client Assessment Form</title>
<style>
/* Add your styles here */
</style>
</head>
<body>
<form action="/submit" method="post">
<h1>Client Assessment Form</h1>
<!-- Personal Information -->
<h2>Personal Information</h2>
<label for="name">Name:</label>
<input type="text" id="name" name="name">
<!-- Add other personal information fields here -->
<!-- Presenting Concerns -->
<h2>Presenting Concerns</h2>
<label for="referralReason">Reason for Referral:</label>
<textarea id="referralReason" name="referralReason"></textarea>
<!-- Add other presenting concerns fields here -->
<!-- Social History -->
<h2>Social History</h2>
<label for="livingSituation">Who else lives there?</label>
<input type="text" id="livingSituation" name="livingSituation">
<!-- Add other social history fields here -->
<!-- Legal History -->
<h2>Legal History</h2>
<label for="legalGuardian">Do you have a legal guardian, representative payee, conservatorship, or special needs trust?</label>
<input type="radio" id="legalYes" name="legalStatus" value="yes">
<label for="legalYes">Yes</label>
<input type="radio" id="legalNo" name="legalStatus" value="no">
<label for="legalNo">No</label>
<!-- Add other legal history fields here -->
<!-- Education -->
<h2>Education</h2>
<label for="gradeCompleted">Highest grade completed:</label>
<input type="text" id="gradeCompleted" name="gradeCompleted">
<!-- Add other education fields here -->
<!-- Employment -->
<h2>Employment</h2>
<label for="employed">Are you employed?</label>
<input type="radio" id="employedYes" name="employmentStatus" value="yes">
<label for="employedYes">Yes</label>
<input type="radio" id="employedNo" name="employmentStatus" value="no">
<label for="employedNo">No</label>
<!-- Add other employment fields here -->
<!-- Military -->
<h2>Military</h2>
<label for="militaryService">Have you or family members served in the military?</label>
<input type="radio" id="militaryYes" name="militaryService" value="yes">
<label for="militaryYes">Yes</label>
<input type="radio" id="militaryNo" name="militaryService" value="no">
<label for="militaryNo">No</label>
<!-- Add other military fields here -->
<!-- Trauma -->
<h2>Trauma</h2>
<!-- Add trauma-related fields here -->
<!-- Flashbacks -->
<label for="flashbacks">Do you experience flashbacks?</label>
<input type="radio" id="flashbacksYes" name="flashbacks" value="yes">
<label for="flashbacksYes">Yes</label>
<input type="radio" id="flashbacksNo" name="flashbacks" value="no">
<label for="flashbacksNo">No</label>
<!-- Nightmares -->
<label for="nightmares">Do you experience nightmares?</label>
<input type="radio" id="nightmaresYes" name="nightmares" value="yes">
<label for="nightmaresYes">Yes</label>
<input type="radio" id="nightmaresNo" name="nightmares" value="no">
<label for="nightmaresNo">No</label>
<!-- Add other trauma-related fields here -->
<!-- Behavioral Health History -->
<h2>Behavioral Health History</h2>
<!-- Add behavioral health history fields here -->
<!-- Suicidal/Homicidal Ideation -->
<label for="thoughtsOfDying">Do you ever think about dying?</label>
<input type="radio" id="thoughtsOfDyingYes" name="thoughtsOfDying" value="yes">
<label for="thoughtsOfDyingYes">Yes</label>
<input type="radio" id="thoughtsOfDyingNo" name="thoughtsOfDying" value="no">
<label for="thoughtsOfDyingNo">No</label>
<!-- Add other suicidal/homicidal ideation fields here -->
<!-- Psychotropic Medications -->
<h2>Psychotropic Medications</h2>
<!-- Add psychotropic medications fields here -->
<!-- Mood -->
<label for="depressedMood">Do you experience depressed mood?</label>
<input type="radio" id="depressedMoodYes" name="depressedMood" value="yes">
<label for="depressedMoodYes">Yes</label>
<input type="radio" id="depressedMoodNo" name="depressedMood" value="no">
<label for="depressedMoodNo">No</label>
<!-- Add other mood-related fields here -->
<!-- Submit Button -->
<input type="submit" value="Submit">
</form>
</body>
</html>
<!-- Sleep -->
<h2>Sleep</h2>
<!-- Add sleep-related fields here -->
<!-- Anxiety -->
<h2>Anxiety</h2>
<!-- Add anxiety-related fields here -->
<!-- Thought -->
<h2>Thought</h2>
<!-- Add thought-related fields here -->
<!-- Assessment/ Plan -->
<h2>Assessment/ Plan</h2>
<!-- Add assessment and plan fields here -->
<!-- STRENGTHS/INTERESTS/COMMUNITY INVOLVEMENT -->
<h2>Strengths/Interests/Community Involvement</h2>
<!-- Add strengths and interests fields here -->
<!-- Life goals -->
<h3>Life Goals</h3>
<!-- Add life goals fields here -->
<!-- Mental Status Exam -->
<h2>Mental Status Exam</h2>
<!-- Add mental status exam fields here -->
<!-- Appearance -->
<label for="appearance">Appearance:</label>
<input type="text" id="appearance" name="appearance">
<!-- Add other Mental Status Exam fields here -->
<!-- PRELIMINARY DSM V DIAGNOSIS -->
<h2>Preliminary DSM V Diagnosis</h2>
<!-- Add DSM V diagnosis fields here -->
<!-- REFERRALS MADE -->
<h2>Referrals Made</h2>
<!-- Add referral fields here -->
</form>
</body>
</html>
Result - Copy and paste this output:
Sandbox Metrics: Structured Data Index 0, 2206 boilerplate words
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