assigment

Psychosocial Assessment

Name: ________________________________________________________________ Gender: __________________ Date of Birth: _____/______/_______ Marital Status ______________ Race/Ethnicity: ___________________________ Languages Spoken: _____________________________________________________

Chief Concern

Past Psychiatric/Psychological History:

Past Medical History:

Drug/ Alcohol Assessment

Suicidal/Homicidal Ideation

Is there a suicide risk? ___ No ___ Yes ___ Previous attempt (When: _____________________________________________) ___ Current plan ___ Means to carry out plan ___ Intent ___ Lethality of plan Is the client dangerous to others? ___ Yes ____ No Does the client have thoughts of harming others? ___ Yes ___ No If yes: Target: __________________________________________________________ Can the thoughts of harm be managed? ___ Yes ___ No ___ Current plan ___Means to carry out plan ___ Intent ___ Lethality of plan High risk behaviors ___ None ___ Cutting ___ Anorexia/Bulimia ___ Head Banging

___ Self injurious behaviors ___ Other: _____________________________________________________________

Abuse Assessment

Has the client the been hit, kicked, or physically hurt by another person in the past year?

Is the client in a relationship with someone who threatens or physically harms them?

Has the client been forced to have sexual contact that they were not comfortable with?

Has the client ever been abused? ___ Yes ___ No. If yes, describe by whom, when and how.

Family/Social History

Born/raised ________________________________________ Siblings ___ # of brothers ___ # of sisters What was the birth order? ____of ____ children Who primarily raised the client? ___________________________________________ Describe marriages or significant relationships:

Number of children: _____________________________________________________ Current living situation: __________________________________________________ Military history/type of discharge: __________________________________________ Support/social network: __________________________________________________ Significant life events:

Family History of Mental Illness (which relative and which mental illness):

Employment

What is the current employment status? ___________________________________ Does the client like their job? _____________________________________________ Will this job likely be done on a long-term basis? _______________________________ Does the client get along with co-workers? __________________________________ Does the client perform well at their job? ____________________________________ Has the client ever been fired? Yes No If yes, explain

How many jobs has the client had in the last five years? ________________________

Education

Highest grade completed: ________________________________________________ Schools attended: _______________________________________________________

Current Legal Status

_____ No legal problems _____ Probation _____ Previous jail

_____ Parole _____ Charges pending _____ Has a guardian

Describe the childhood: Describe the childhood in relation to personality, school, friends, and hobbies): Describe any traumatic experiences in the childhood: (List the age when they occurred)

What is the client’s sexual orientation?

___ Heterosexual ___ Homosexual ___ Bisexual

Spiritual Assessment

Religious background: ___________________________________________________ Does the client currently attend any religious services? Yes No If yes, where.

Cultural Assessment

List any important issues that have affected the ethnic/cultural background.

Financial Assessment

Describe the financial situation.

Coping Skills

Describe how the client copes with stressful situations.

Is the client’s coping methods: ___ adaptive ___ maladaptive

Interests and Abilities

What hobbies does the client have? What is the client good at?

What gives the client pleasure?

MENTAL STATUS ASSESSMENT

(Describe any deviation from normal under each category.)

Appearance

___ Well groomed ___ Good eye contact ___ Poor eye contact ___ Disheveled ___ Bizarre ___ Poor hygiene ___ Inappropriate dress ___ Other:____________________________________________________________

Mood/Affect

___ Normal ____ Depressed ___ Flat ____ Euphoric ___ Anxious ___ Irritable ___ Liable ___ Indifferent ___ Careless ___ Inability to sense emotions ___ Lack of sympathy ___ Other:_____________________________________________________________

Impulse Control

___ Normal ___ Partial ___ Limited ___ Poor ___ None ___ Frequently participates in activities without planning or thinking about them

Judgment

(What would you do if there was a fire in a crowded movie theater?)

___ Normal ____ Poor

Is the client able to meet their basic needs (e. g., food, shelter, medical):

___ Yes ___ No If no, Describe:

Functional Ability