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INITIAL PSYCHOSOCIAL ASSESSMENT QUESTIONNAIRE

Client:_____________________________________________ Intake Date: ________________________

Date of Birth: ______- ______ - ______ Age: _______ Sex: M F Race: __________________

Interviewer: __________________________________________________

_______________________________________________________________________________________

Current Family/Support System: (Current family household composition and relationships)

________________________________________________________________________________________

Presenting Problem: Short statement about immediate concern, current situation, and by whom referred. (List symptoms/onset/duration/precipitating events/current stressors)

Client Interview: ________________________________________________________________________________________

________________________________________________________________________________________

Current Level of Functioning: (Assess sleep/appetite/mood/energy/substance use)

Sleep___________________________________________________________________________________

Appetite_________________________________________________________________________________

Energy Level_____________________________________________________________________________

Attention_________________________________________________________________________________

Mood___________________________________________________________________________________

Hallucinations/Delusions____________________________________________________________________

Other___________________________________________________________________________________________________________________________________________________________________________

Risk Assessment:

Suicidal Ideation

__________________________________________________________________________________

Homicidal Ideation

__________________________________________________________________________________

Safety Plans

__________________________________________________________________________________

Mental Health Treatment History:

History of Problems/Age at First Diagnosis: No Yes

__________________________________________________________________________________

Past Outpatient Treatment: No Yes

__________________________________________________________________________________

Past Inpatient Treatment: No Yes

__________________________________________________________________________________

Family History of Mental Health treatment/Diagnosis: No Yes

__________________________________________________________________________________

Relevant History:

Family Issues: No Yes

__________________________________________________________________________________

Physical Abuse: No Yes

__________________________________________________________________________________

Sexual Abuse: No Yes

__________________________________________________________________________________

Other Trauma: No Yes

__________________________________________________________________________________

Educational History:

__________________________________________________________________________________

Medical History:

Present Physical condition:

__________________________________________________________________________________

History of Illness, Injury, or Surgery: No Yes

__________________________________________________________________________________

Medications: (Six month history of prescribed and over-the-counter medication including dose prescriber/when taken/illness/results)

__________________________________________________________________________________

Legal History:

Current or Pending Legal Involvement: No Yes

__________________________________________________________________________________

Past Legal Involvement: No Yes

__________________________________________________________________________________

Alcohol and Drug History and Current Use:

(Include all drugs ever abused/onset of use, average quantity and frequency/last use/route of administration)

__________________________________________________________________________________

Employment History:

__________________________________________________________________________________

Summary and Intervention Recommendations:

__________________________________________________________________________________

TREATMENT GOAL:

__________________________________________________________________________________

TREATMENT ACTION STEPS:

1. __________________________________________________________________________________

2. __________________________________________________________________________________

3. __________________________________________________________________________________

Clinician Signature: ______________________________________________ Date: __________________

(rev. 8/18) 1