Adult Psychosocial Assessment 1

Adult Psychosocial Assessment
Name_________________________________ DOB_________________________
PRESENTING PROBLEM: What brings you here today?
_____________________________________________________________________________________
_____________________________________________________________________________________
Mental Health History
Please circle all that apply to you (choose severity that applies):
(0) Not Present, (1) Mild, (2) Moderate, or (3) Severe)
Depression 0123 Panic Attacks 0123

Anxiety 0123 Memory Problems 0123 Obsessive Thoughts 0123
Mood Swings 0123 Loss of Interest 0123 Ritualistic Behavior 0123
Appetite Changes 0 1 2 3 Irritability 0123 Checking 0123
Sleep Changes 0 1 2 3 Excessive Worry 0123 Counting 0123
Hallucinations 0 1 2 3 Suicidal Ideation 0123 Self-Injury 0123
Work Problems 0 1 2 3 Relationship Issues 0123 Difficulty
Racing Thoughts 0 1 2 3 Low Energy 0123 Concentrating 0123
Confusion 0123 Hyperactivity 0123
Describe a brief history of your present symptoms:
_____________________________________________________________________________________
_____________________________________________________________________________________
What effect have they had on your life?
_____________________________________________________________________________________
_____________________________________________________________________________________
Have you ever been treated for a mental health problem? If yes, please describe:
_____________________________________________________________________________________
_____________________________________________________________________________________
Have you ever had a mental health hospitalization? ___No ___ Yes, please describe:
_____________________________________________________________________________________
1
Medical History
Previous surgeries/Major Illness/Medical Diagnoses (please include reason and year)
_____________________________________________________________________________________
_____________________________________________________________________________________
Please list any additional health information that may be important for your therapist to know (including
any medication or other allergies or problems with pain):
_____________________________________________________________________________________
_____________________________________________________________________________________
List daily medications and Dosages (including over the counter medications)
Current Dosage Prescribing Last Dose Taking as

Medication Physician Prescribed?
Are you having any difficulty with pain? No____ Yes; please describe:
_____________________________________________________________________________________
_____________________________________________________________________________________
Are there any guns in your home? ___ No ____ Yes
Have you ever:
Binged on food? _________ Gone without eating? ___________ Vomited on purpose?________
Used laxatives to purge? ________
Marital/Social Relationships
Are you: ___ Single ___ In a relationship ___Married ___ Divorced ___ Separated ___ Widowed
How many times have you been married? ______ Dates of previous marriages? _____________
Do you have any concerns regarding your marriage or relationship?
_____________________________________________________________________________________
_____________________________________________________________________________________
2
Do you have any children? ___ No ___Yes; how many? _____ Please list their sex and ages:
_____________________________________________________________________________________
_____________________________________________________________________________________
Do you regularly engage in social activities? ___ No ___ Yes
Do you have a social support network? ___ No ___Yes
Family History
Describe the family in which you were raised:
_____________________________________________________________________________________
_____________________________________________________________________________________
Describe your current relationship with your family of origin:
_____________________________________________________________________________________
_____________________________________________________________________________________
Is there any history of mental health or substance abuse problems in your family? ___No ___Yes:
Please explain:
_____________________________________________________________________________________
_____________________________________________________________________________________
Did you experience any physical, emotional, or sexual trauma in your childhood? ____No _____Yes
If yes, please explain:
_____________________________________________________________________________________
_____________________________________________________________________________________
Educational History:
How far did you go in school? _____________________________________________________
Did you have any learning or behavioral issues in school? ___ No ____Yes; please explain:
_____________________________________________________________________________________
_____________________________________________________________________________________
Work History
Do you work? ____No _____Yes If Yes:
Name of Employer _________________________________ Length of Employment ________________
Do you like your job? Why or why not? ____________________________________________________
3
Substance Use
Do you use tobacco? ___No ___Yes, amount per day? ____ How many years at this frequency?______
Do you use alcohol? ___No ___Yes, what type? ______________ Frequency?______________
When was your last drink? ______________ How much? _________________
Have you ever experienced any form of withdrawal symptoms, such as hallucinations, tremors,
excessive sweating, nausea, or vomiting? ____No _____ Yes; please explain:
_____________________________________________________________________________________
_____________________________________________________________________________________
Have your ever experienced blackouts? ____No ____ Yes, how frequently? ______________________
Have you ever used illicit drugs or taken more medication than prescribed? ___No ____ Yes; what
type?________________________________________________________________________________
Frequency? __________________________________ Date of last use: __________________________
If you are not presently using, have you ever used in the past? ___ No ____ Yes; What types of alcohol
or other substances have you used? _____________________________________________________
Frequency? ______________________ Last used: __________________________________________
Have you ever received treatment for substance abuse? ____ No _____ Yes; Name of agency, type of
treatment, and dates:
_____________________________________________________________________________________
_____________________________________________________________________________________
Have you ever been involved in any recovery or support programs? ___ No ____ Yes; please explain:
_____________________________________________________________________________________
_____________________________________________________________________________________
Are you aware of your triggers to drink or use? ____ No ____ Yes; please explain:
_____________________________________________________________________________________
_____________________________________________________________________________________
Have you ever had any legal issues related to the use of alcohol or other drugs? ___ No ___ Yes; please
explain, including name of offense and dates:
_____________________________________________________________________________________
_____________________________________________________________________________________
Client Signature Date

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Adult Psychosocial Assessment

PRESENTING PROBLEM: What brings you here today?

Mental Health History

(0) Not Present, (1) Mild, (2) Moderate, or (3) Severe)

Depression 0123 Panic Attacks 0123

What effect have they had on your life?

Previous surgeries/Major Illness/Medical Diagnoses (please include reason and year)

Current Dosage Prescribing Last Dose Taking as

Are there any guns in your home? ___ No ____ Yes

Have you ever:

Binged on food? _________ Gone without eating? ___________ Vomited on purpose?________

Used laxatives to purge? ________

Do you have any concerns regarding your marriage or relationship?

Do you regularly engage in social activities? ___ No ___ Yes

Do you have a social support network? ___ No ___Yes

Describe the family in which you were raised:

If yes, please explain:

How far did you go in school? _____________________________________________________

Do you work? ____No _____Yes If Yes:

Name of Employer _________________________________ Length of Employment ________________

Do you like your job? Why or why not? ____________________________________________________

Do you use alcohol? ___No ___Yes, what type? ______________ Frequency?______________

When was your last drink? ______________ How much? _________________

Frequency? __________________________________ Date of last use: __________________________

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Are there any guns in your home? _ No __ Yes

Binged on food? ___ Gone without eating? _ Vomited on purpose?____

Do you regularly engage in social activities? _ No _ Yes

Do you have a social support network? _ No _Yes

Do you work? No _Yes If Yes:

Name of Employer _________________ Length of Employment

Do you use alcohol? _No _Yes, what type? Frequency?

When was your last drink? How much? ___

Frequency? ________ Date of last use: