Psychosocial Assessment s

image1.jpg Psychosocial Assessment ____ Part 1 (Topic 2)

Template ____ Part 2 (Topic 3)

Name: ______________________________ Date: _________________ DOB: ________________

Age: ________________________________ Start Time: ____________ End Time: ___________

Identifying Information:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Presenting Problem:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Life Stressors:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Substance Use/Abuse: FORMCHECKBOX Yes FORMCHECKBOX No

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Addictions (i.e., gambling, pornography, video gaming)

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Medical/Mental Health Hx/Hospitalizations:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Abuse/Trauma:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Social Relationships:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Family Information:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Spiritual:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Suicidal:

________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________

Homicidal:

________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________

Assessment:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Initial Diagnosis (DSM):

________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Initial Treatment Goals:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Plan:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Name: _____________________________________________ Date: _________

"Is this question part of your assignment? We can help"

ORDER NOW