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Double Board Certified Counseling Services
Mark Zauss, LMHC, LPC, CCMHC, NBCC, BC-TMC, ADHD-CCSP, C-DBT, CCTP
Isolation Intake & Self-Assessment
This form helps identify patterns of social withdrawal and isolation. Please answer honestly. Scoring is for education, not diagnosis.
Patient Information
Isolation Pattern Questions
Rate how often the following apply: (0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Often, 4 = Very Often)
Additional Notes
This tool is for educational purposes only and does not replace professional evaluation. Please discuss your results with your therapist.
isolation intake form, social withdrawal assessment, mental health self-report, Double Board Certified Counseling Services, Mark Zauss