PSYCHOSOCIAL ASSESSMENT HISTORY

Date of appointment:

Client Name:

Presenting Problem:

Family background

1. Who lives with you since birth before you get married?
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2. Were there any people not part of the family living in your home? How’s your relationship with
them?
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3. Please describe your relationship with your father when he was still alive.
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4. Please describe your relationship with your mother.
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5. Please describe your relationship among your three siblings.
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6. What were the rules like at home?
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7. What kinds of things did you and your family argue about the most? What happened at home
when there was an agreement?
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8. If you can change the past, is there anything you would like to change in the family?
_____________________________________________________________________________
9. Did you experience physical abuse? How?
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Education and Employment

1. What do you like best when you were in Elementary, High School and College?
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2. Did you missed classes or work? Have you ever been suspended from school or work?
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3. How did you get along with your classmates? Officemates?
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4. How do you get along with peers? Did you experience bullying?
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Activities

1. Do you hangout with mainly people of your same sex or a mixed crowd?
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2. Do you have a lot of friends?
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3. What do you do to get along with family and friends?
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4. Do you prefer parties and get drunk or a simple coffee date with friends?
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5. Do you do any regular sport or exercise?
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6. What are your hobbies and interests?
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Others

1. Do any of your family members drink, smoke or use other drugs? Is it a problem for you?
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2. Do your close friends drink, smoke or use drugs?
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3. Do you drink, smoke or use drugs?
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4. Have you ever been involved in car accident and was it related to being drunk?
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5. How long you have been together with your husband?
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6. What is sex for you? How is your sex life with your husband?
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7. Are you using contraception?
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8. Have you had an experience in the past where someone did something to you that you did not
feel comfortable with or that made you feel disrespected?
_________________________________________________________________________
9. If someone abused you, how would you react to this?
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10. To whom you can trust and confide in if you have problems?
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11. Is there anything else that you would like to talk about?
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