Psychosocial Assessment Form
Client’s Name: ______SS#______
Instructions: Please fill in all blanks with detailed information or put N/A if it does not apply.(To be completed by the client)
I. Presenting Program
What are the primary problems/ circumstances you have been experiencing which led to your need for treatment?
______
Put a check next to your current symptoms:
___Increased Anxiety___ Depressed Mood___Low Energy Level
___ Racing thoughts___Poor concentration___Indecisiveness
___Sleep disturbance___Appetite disturbance___Angry outbursts
___Crying Spells___Lack of motivation___Recent Weight Change
___Excessive Guilt___Isolating from others___feelings of hopelessness
___Low self-worth___Mood Swings___Difficulty with memory
___Paranoia___Thoughts / Intentions/ Plans of hurting yourself
___Inability to stop using drugs / chemical___Inability to stop using alcohol
II. Current Situation
- Family Structure / Living Situation
Who lives with you, and what are their ages?
______
Describe your living situation and relationship with those listed above.
______
- Vocational / Occupational/ Financial Situation
Where are you employed? ______Position / Job Title______
Duration of employment? ______Income______
Identify any history of being in the military.
______
C. Religious Affiliation and History
Describe the religious environment of the home in which you were raised. ______
Describe your view of God. ______
Worship location(name) and frequency of attendance. ______
______
Identify any involvement in religiousactivities or spiritual organizations.
______
What do you consider to be the role of God in your recovery? ______
Have you ever been involved in a cult or the occult? ______
Identify any hobbies or interests you may have. ______
III. Social Background (Individual and Family History)
- Individual Information
Cultural / Ethnic Orientation:______
Where were you born and raised?______
Identify the socioeconomic status of your family of origin.
___Lower Class __Middle Class __Upper – Middle Class___Upper Class
B. Developmental History
Are you aware of your mother having any problems during her pregnancy or birth of you? ______
Describe any emotional or physical problems you had during your childhood and adolescence. ______
What were you like as a child and a teenager?
______
C. Parents
Identify your father’s name, age, location, and occupation.
______
Describe the history of your relationship with your father.
______
Identify your mother’s name, age, location, and occupation.
______
Describe the history of your relationship with your mother.
______
Briefly describe your parents’ marital history.
______
Do your parents have any criminal history? ______
D. Siblings (Brothers and Sisters)
______
E. Health/Illness
Identify the history of physical illnesses / injuries to your family of origin and current family.
______
Identify the history of psychiatric / emotional / drug / alcohol / problems and treatment in your family of origin and current family. ______
IV. Individual History as Related to the Client.
Identify significant memories from your childhood and adolescence. ______
B. Educational History
Where and when did you graduate from high school? ______
Identify any educational training/college you completed after high school? ______
Identify any learning difficulties? ______
C. Marital History
Current Marriage
Name of Spouse: ______Age: ______
Year of Marriage: ______
Names and ages of children: ______
Describe the history of your relationship with your spouse. ______
Previous Marriage
Name of ex- spouse: ______
Year of Marriage: ______Year of divorce: ______
Reason(s) for divorce: ______
Names and ages of children: ______
Describe the relationship: ______
FOR ADDITIONAL MARRIAGES DESCRIBE THE SAME INFORMATION ON THE BACK OF THE FORM.
D. Medical History
Identify your history of any previous psychiatric/ drug and alcohol treatment or counseling. Be specific. ______
Identify any previous drug/ alcohol overdoses or suicide attempts. ______
Identify past and present Medication History (Type, Quantity, dates)
______
Identify any history of abortions or miscarriages. ______
Identify your history of serious illnesses or injuries. ______
Have you had an eating disorder? ______
___Anorexia___Bulimia___Compulsive Overeating
Describe any situations in which you were ever sexually abused. Identify your age at the time of the offense and the age of the abuser (N/A – it does not apply). ______
Identify any situationswhereyou weresexually abusive towards others. Identify your age at the time and the age of the victim (N/A – it does not apply). ______
Describe any sexual problems you are currently experiencing (optional). ______
G. Substance/Alcohol Use History
How old were you when you were introduced to the use of: Alcohol _____ Drugs ____
Describe your alcohol/ drug use (all drugs). Number drugs in the order in which they were taken.
Substance / Age Started / Age Stopped / Ongoing use? / Identify Quantity and Frequency / Method of use (IV, Oral, Etc…) / When was the last time you used?Marijuana
Amphetamine
L.S.D
Hallucinogen
Heroin
Barbiturate
Morphine
Cocaine
Crack
Alcohol
Cigarettes
Other Drugs (Specify)
Other Drugs (Specify)
Other Drugs (Specify)
Other Drugs (Specify)
G. Alcohol/ SubstanceUse History (cont’d)
Put a check next to those that apply:
___ I have a drinking problem___ I have a drug problem
___My goal is to quit alcohol / drugs___ My goal is to control / reduce usage
When and where are you most likely to use or drink (High Risk Situations): ______
Identify the effects of your drug / alcohol use on your financial condition. ______
List Symptoms / Consequences of using (check all that apply):
___Drinking / Using___Convulsions___Drinking / Using Less___Nausea / Vomiting/ Upset Stomach
___Daily use for 2 or more weeks___Sweating___Loss of control___Muscle Cramps
___Withdrawal symptoms/ tremors/ shakes___DT’s___Morning drinks/ using
___Liver problems___Blackouts / memory loss___Diabetes
___Needed it or depended on it___Overdose___Hallucinations (seeing or hearing things)
___Passing out/ fainting___Emotional / psychiatric problems___Physical/ Health problems
G. Alcohol / Drug History (cont’d)
Have you attempted to stop drinking / using without outside help? ___Yes ___No
If yes, how? ______
Have you had any other medical complications due to your alcohol / drug use? (Specify) ______
Do you have a history gambling problems? (If so, specify kind of gambling, frequency, and money involved) ______
H. Legal History
Have you ever been arrested? ____When (month, year)? ______Offense(s)? ______
Outcome (imprisonment, probation, etc.)? ______
Any pending legal issues?____Yes ____No
Ifyes,explain? ______
Name and address of probation or parole officer. ______
______
Christopher Merrell, LPC Phone: 469-337-1160/ Fax: 972-218-7754 1106 Sante Fe Trail Suite 3, Duncanville, Texas 75137