Adult Assessment

Lakeside Family Center, LLC 1714 S Live Oak Drive/402 S Live Oak Dr Moncks Corner SC 29461

Part 1:   Please complete ALL Questions in this google form: Assessment Part 1.

Part 1 of the Assessment will be completed by client or client’s caregiver if a child.  This section is helpful in preparing providers with information needed in assessing client’s treatment needs and diagnosis evaluation.  Client is to complete ALL sections of this Assessment to ensure the best outcome of determining treatment needs.  This part of the Assessment MUST be completed in order for the client to attend their assessment visit.  This section can be completed at home prior to the visit or Client may attend visit no later than 30 minutes prior to appointment to complete this information.  

Part 2:   Part 2 of the Assessment will be completed by the provider once the client has completed the Assessment appointment.  Provider will summarize all information provided by the written part 1; along with information provided during the visit.  Provider will formulate a diagnosis and recommended plan of care from this visit.   

Both part 1 and part 2 of the Assessment will be considered as the Assessment in regards to your Medical Records.  

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Client's Name *
Client's date of birth *
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Client's Social Security Number *
Client's Driver's License *
Physical Address:  NO PO Boxes will be accepted in place of the complete physical address *
 Email Address:
Is it ok to email you *
Home/ Cell Phone Number *
Work Phone Number: *
 Name of  Emergency Contact *
Emergency Contact's Phone Number *
Emergency Contact's relationship to you *
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