Adult Psychosocial Assessment
Name:
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
Date
Presenting Problem: What brings you here today?
Mental Health History
Please rate the severity in which you experience the following symptoms - (0) Not present, (1) Mild, (2) Moderate, or (3) Severe
Depression:
0
1
2
3
Anxiety:
0
1
2
3
Mood Swings:
0
1
2
3
Appetite Changes:
0
1
2
3
Sleep Changes:
0
1
2
3
Hallucinations:
0
1
2
3
Work Problems:
0
1
2
3
Racing Thoughts:
0
1
2
3
Confusion:
0
1
2
3
Memory Problems:
0
1
2
3
Loss of Interest:
0
1
2
3
Irritability:
0
1
2
3
Excessive Worry:
0
1
2
3
Suicidal Ideation:
0
1
2
3
Relationship Issues:
0
1
2
3
Low Energy:
0
1
2
3
Panic Attacks:
0
1
2
3
Obsessive Thoughts:
0
1
2
3
Ritualistic Behavior:
0
1
2
3
Checking:
0
1
2
3
Counting:
0
1
2
3
Self-Injury:
0
1
2
3
Difficulty Concentrating:
0
1
2
3
Hyperactivity:
0
1
2
3
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?
Yes
No
If yes, please describe:
Have you ever had a mental health hospitalization?
Yes
No
If yes, please describe:
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 Medication
Dosage
Prescribing Physician
Last Dose
Taking as Prescribed?
1
2
3
4
Are you having any difficulty with pain?
Yes
No
If yes, please describe:
Are there any guns in your home?
Yes
No
Have you ever:
Binged on food?
Gone without eating?
Vomited on purpose?
Used laxatives to purge?
Marital/Social Relationships
Are you:
Single
In a relationships
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?
Do you have any children?
Yes
No
If yes, how many?
Please list their sex and ages:
Do you regularly engage in social activities?
Yes
No
Do you have a social support network?
Yes
No
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?
Yes
No
If yes, please explain:
Did you experience any physical, emotional or sexual trauma in your childhood?
Yes
No
If yes, please explain:
Educational History
How far did you go in school?
Did you have any learning or behavioral issues in school?
Yes
No
If yes, please explain:
Work History
Do you work?
Yes
No
Name of Employer:
Length of Employment:
Do you like your job? Why or why not?
Substance Use
Do you use tabacco?
Yes
No
If yes, amount per day?
How many years at this frequency?
When was your last drink?
How much?
Have you ever experienced any form or withdrawal symptoms, such as hallucinations, tremors, excessive sweating, nausea or vomiting?
Yes
No
If yes, please explain:
Have you ever experienced blackout?
Yes
No
If yes, how frequently?
Have you ever used illicit drugs or taken more medication that prescribed?
Yes
No
If yes, what type?
Frequency?
Date of last use:
If you are not presently using, have you ever used in the past?
Yes
No
What types of alcohol or other substances have you used?
Frequency:
Last used:
Have you ever received treatment for substance abuse?
Yes
No
Name of agency, type of treatment and dates:
Have you ever been involved in any recovery or support programs?
Yes
No
If yes, please explain:
Are you aware of your triggers to drink or use?
Yes
No
Please explain:
Have you ever had any legal issues related to the use of alcohol or other drugs?
Yes
No
If yes, please explain, including name of offense and dates:
Client Signature:
Date:
-
Month
-
Day
Year
Date
Submit
Should be Empty: