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    Psychosocial Assessment Form1 PDF

    Uploaded by

    WindiGameli
    This document contains a psychosocial assessment of an individual. It collects information on their appearance, mood, functioning, support systems, living situation, substance use history, mental health history, history of abuse, and parenting skills (if applicable). Areas of concern are identified. A counseling intervention plan is outlined with goals and a timeline. This assessment will inform counseling to address the client's needs.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Psychosocial Assessment Form1 PDF

    Uploaded by

    WindiGameli
    375 views4 pages
    This document contains a psychosocial assessment of an individual. It collects information on their appearance, mood, functioning, support systems, living situation, substance use history, mental health history, history of abuse, and parenting skills (if applicable). Areas of concern are identified. A counseling intervention plan is outlined with goals and a timeline. This assessment will inform counseling to address the client's needs.

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    psychosocial-assessment-form1.pdf

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    This document contains a psychosocial assessment of an individual. It collects information on their appearance, mood, functioning, support systems, living situation, substance use history, mental health history, history of abuse, and parenting skills (if applicable). Areas of concern are identified. A counseling intervention plan is outlined with goals and a timeline. This assessment will inform counseling to address the client's needs.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    375 views4 pages

    Psychosocial Assessment Form1 PDF

    Uploaded by

    WindiGameli
    This document contains a psychosocial assessment of an individual. It collects information on their appearance, mood, functioning, support systems, living situation, substance use history, mental health history, history of abuse, and parenting skills (if applicable). Areas of concern are identified. A counseling intervention plan is outlined with goals and a timeline. This assessment will inform counseling to address the client's needs.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 4
    At a glance
    Powered by AI
    This assessment evaluates several areas of a client's psychosocial functioning including mood, substance use, medical history, family/social support systems, and living situation to develop a holistic understanding of their needs.

    The purpose of this assessment is to evaluate a client's psychosocial functioning through a clinical interview and use of checklists to identify problems, strengths, limitations and barriers to care in order to inform treatment planning.

    This assessment evaluates a client's mood, substance use, medical history, family and social support systems, living situation, history of abuse, parenting skills and cultural/religious factors to develop a holistic understanding of their needs and functioning in different life areas.

    I~

    Psychosocial Assessment
    Directions: After the assessment interview, check off items that apply. Write
    infOrmation obtained from the interview. If subject area is not applicable, write NIA.

    Status:
    Appearance and General Behavior
    0 Appropriate attire
    0
    0 Clothing disheveled
    0
    0 Poor hygiene
    0
    0 Cooperative
    0

    Name:
    IDNo:
    Date of Birth:
    ------------------------------Date of Initial Assessment:

    Oriented to time, place and person


    Disoriented/confused
    Pressured speech
    Psychomotor retardation

    0
    0
    0
    0

    Guarded/avoidant
    Uncooperative
    Agitated
    Other:

    Comment-------------------------------------------------------------------------------------Mood/Affect
    0 Normal mood
    0 Labile
    0 Depressed/sad
    0 Appropriate to content
    0 Irritable
    0 Anxious
    0 Adaptable
    0 Inappropriate to content
    0 Other: - - - - - - - - - - - - - 0 Euphoria/elated
    0 Flat affect
    0 Angry/hostile
    0 Anhedonia
    Comment: __~~--~~~-----------------------------------------------------------------------General Functioning/Behavior
    0 Able to abstract
    0 Potential for suicidal ideation
    0 Impaired concentration memory
    0 Limited insight
    0 Social withdrawal/isolation
    0 Logical/goal directed
    0 Alert
    0 Poor anger management
    0 Articulates needs and issues
    0 Fully oriented
    0 Low self esteem
    0 Impaired judgment
    0 Poor impulse control
    0 Decreased attention span
    0 Other: --------------------------Comment: ___________________________________________________________________________________
    Coping Mechanisms/Resources
    0 Adequate problem solving skills
    0 Able to ask for assistance
    0 Able to live independently
    0 Able to articulate needs/concerns
    0 Adequate coping/stress management skills
    0 Insight oriented
    0 Good judgment
    0 Able to reach out to others
    0 Takes responsibility for actions
    0 Able to make decisions
    0 Appropriate emotional expression
    0 Other: --------------------------Comment:-------------------------------------------------------------------------------------Living Status
    0 HUD housing
    0 Lives with friends
    0 Independent
    0 Group/institutional
    0 Lives with family
    0 Other: - - - - - - - - - - - - 0 Homeless/shelter
    0 Lives with partner
    Comment-------------------------------------------------------------------------------------Support Network/Resources
    0 Substance abuse treatment
    0 Family
    0 12 step program: ------------------0 None
    0 Friends/co-worker
    0 Mental health agency: ----------------0 Community support group/agencies
    0 Religious/social affiliation
    0 Significant other
    Comment:

    Perception of Support System as Reported by Participant:

    Receiving Services from Other Agencies/Service Providers: 0 Yes

    0 No

    Agencies: -----------------------------------------------------------------------------

    Significant Cultural/Religious Issues: 0 Yes

    DH 3184, 11/G8
    Stock Number. 5744-000-3184-6

    0 No

    Name:
    Involvement with Legal System:

    D Current

    D Past

    D No

    S~~s~Curffi~Legallnvo~ement ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    c1garettes.'Smo keIess To b acco

    (Pre-contemplation)

    (Contemplation/Preparation)

    (Action)

    Current usage:
    I DYes I D No I D Does not want to quit I D Wants to quit
    ID Ready to quit
    Other household members:
    I DYes I D No I D Does not want to quit I D Wants to quit
    ID Ready to quit
    Client has (increased) (decreased) tobacco use: (cigarettes) (smokeless tobacco) (other:
    )
    Education provided:
    D Tobacco use
    D Second hand smoke risk
    J Has tobacco related illness:
    # of successful (> one week) quit attempts in lifetime:
    If pregnant, stopped usage upon learning of pregnancy: I D Yes I D No I During pregnancy, started usage again: DYes
    Alcohol
    History of Dependency/Addiction: I D Yes
    ID No
    Type:
    Current Use of Alcohol:
    Readiness for Change:
    D Pre-contemplation
    Alcohol treatment
    D Yes I D No I Provider:
    If pregnant, stopped usage upon learning of pregnancy:

    Family History of Dependency/Addiction: DYes D No


    Frequency:
    Amount:
    D Contemplation/Preparation
    D Action
    ID N/A
    Last date treated:
    DYes I D No
    I

    Other Drugs
    Family History of Abuse/Addiction:
    History of Addiction
    DYes
    I D No
    I DYes
    Current Use
    Type:
    Frequency:
    I Amount:
    D Cocaine/Crack I D Hallucinogens
    D Marijuana
    D Opiates
    ID Benzodiazepines
    D Prescription med.:
    D Amphetamine
    D Barbiturates
    I D Inhalants
    Readiness for Change: D Pre-contemplation I D Contemplation/Preparation I D Action
    I D N/A
    Drug Treatment
    I Provider:
    I Last Date Treated:
    DYes I D No
    If pregnant, stopped usage upon learning of pregnancy:
    DYes
    I D No I

    I D No

    Mental Health History


    Mental health history
    Depressed mood
    Social impairment, including family relationship
    Impairment in occupational functioning/ADLS
    Impairment in school functioning
    Other:
    Other:

    Current
    D
    D
    D
    D
    D
    D
    D

    Past
    D
    D
    D
    D
    D
    D
    D

    Marital discord
    Suicidal plan/attempt
    Family dysfunction
    Impairment of judgment
    Anxious Mood
    Poor conduct/impulse control
    Familial history:

    Current
    D
    D
    D
    D
    D

    Past
    D
    D
    D
    D
    D

    0
    0 Yes

    0
    D No

    Mental Health/Substance Abuse History: TreatmenUDates/Follow-up/Response:

    History of Sexual Abuse


    Current:
    Assistance sought:
    Situation/

    Past Hx:
    DYes
    Assisted by:

    D No

    Status:
    History of Physical/Emotional Abuse or Domestic Violence
    D No
    Situation/

    Status:

    ***If Pregnant:
    Presenting Feelings Regarding this Pregnancy/Significant
    Concerns and Priorities:

    Name:
    IDNo:
    Date of Birth: _ _ _ _ _ _ _ __

    Significant Pregnancy History, Family Planning Issues, Child Spacing Information:

    ***If Adolescent

    Pregnancy:

    Educational Status/Issues:
    Family/FOB Reaction to
    Pregnancy/Infant:

    Attachment Issues:

    Income/Support Issues:
    Other:

    Parenting
    0 Realistic expectations
    0 Unrealistic expectations
    0 Anger managemenUself-control
    0 ParenUchild interaction issues
    0 Other:

    0 Parenting technique/discipline issues


    0 Children not living in the home:
    0 Child protection issues:
    0 Caregivers are aware of the dangers of shaking a child

    Parenting: Attachment Issues/Concerns/Priorities/Parental Relationship/Relationship with Children In the House:

    DH 3164, 11198
    Stock Number: 5744-000-31&4-6

    Name:
    Psychosocial Assessment/Pre-Counseling Summary
    Identification of Problems/Assets/Limitations/Barriers to Care/etc. (Address Any Checked Items Requiring Further Clarification)

    Psychosocial Counseling Intervention Plan


    State Need for Counseling, Develop Plan with Client; Establish Goals with Dates for Completion and Frequency of
    Counseling Sessions.

    Psychosocial Counseling Intervention Plan Update


    Update Counseling Plan Goals Here. (Individual Counseling Session Progress Should be Recorded in the Progress Notes)

    Date of Update: - - - - - - - Signature of Psychosocial Counseling/Assessment Provider:


    Psychosocial Assessment Date:

    Title:

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