PSYCHOSOCIAL ASSESSMENT

DATE:
CLINICIAN:
CLIENT NAME:
INSURANCE:

Privacy/Confidentiality/Mandated reporter
Virtual room rules
Cancellation/Reschedule policy
Communication outside of session
Emergency/crisis

Presenting problem:

Presentation of sxs:

Current/recent/upcoming stressors:

History of present complaint:

Mental health treatment hx:

 RISK ASSESSMENT

Suicidal ideation No current No history

Plans/preparatory bx/means to carry out plan No current No history

Intent No current No history

Suicide attempts No current No history

Protective factors:

Risk factors:

Danger to others/Thoughts of harming others? No current No history

Target/plan/intent No current No history

Other high-risk behaviors/self-injurious bxs No current No history

Risk assessment

Acute Low Moderate High

Chronic Low Moderate High

Safety plan
 HISTORY OF ABUSE/TRAUMA

Experienced or witnessed physical/verbal/emotional abuse Denies

Experienced, witnessed, or threatened by physical assault Denies

(Example: being kicked, hit, beaten, threatened with a weapon)

Experienced, witnessed, or threatened by serious and/or disturbing accident, injury, disaster, or death
Denies

Experienced, witnessed, or threatened by sexual assault and/or violence Denies

Other:
 MEDICAL AND MEDICAL HISTORY

Hx of mental health conditions None

Hx of medical/physical conditions that impact daily functioning None

Current providers:

Sleep Normal Difficulty w/ Falling asleep Night awakenings Early awakenings

Energy Normal Low High

Sex drive Normal Low High

Appetite Normal Low/Lack of Excessive

Medication Dose Frequency Prescriber Reason

Alcohol None

Marijuana None

Nicotine None

Caffeine None

Other None
 FAMILY AND SOCIAL HISTORY

Born and raised:

Raised by:

Brothers None
Sisters None

Family history of mental illness or addiction:

Describe home environment:

Describe school experience:

Academic:
Social:
Behavioral:
Activities:

Early adulthood experiences:

Current living situation Alone

Current/significant relationships

Children/dependents None

Support/social networks:

Current legal status (Probation, parole, hx of incarceration)

No legal problems

Financial assessment (How are you feeling about your current financial situation?)
No financial concerns

Spiritual assessment (What are your spiritual or religious beliefs?)

Cultural assessment (Any significant issues or impact due to ethnic/cultural background?)

Coping skills (How do you deal with stressful situations?)

Interests, hobbies, fun