Presenting Problem (Reason You Are Here): ______

Initial Psychosocial Assessment

NAME: ______

DATE: ______

DATE OF BIRTH: ______

Referred by: ______

Presenting Problem (reason you are here): ______

PROFESSION:______

CURRENTLY EMPLOYED?______Y______N

EMPLOYER:______

HOW LONG WITH THIS EMPLOYER?______

HIGHEST LEVEL OF EDUCATION:______

HIGH SCHOOL:______

COLLEGE:______

FINANCIAL STATUS: FINANCIAL STRESS______Y______N

PLEASE DESCRIBE ANY FINANCIAL STRESSORS:______

______

FAMILY SYSTEM:

MARITAL STATUS: ______

SPOUSE:______AGE: ______

CHILDREN(names and ages: ______

MOTHER______LIVING:____Y______N FATHER______LIVING:____Y______N

STEP PARENTS______LIVING____Y_____N___

SIBLINGS:______

SOCIAL SUPPORTS: ______

MEDICAL ILLNESSES: ______

______

PRESCRIBED MEDICATIONS and REASON:______

______

MENTAL HEALTH HISTORY:

DEPRESSION ____Y_____N

If “yes” : ____broken sleep _____frequent waking_____difficulty falling asleep ___excessive sleep/fatigue/tiredness_____lowenergy_____irritability____mood swings ______agitation ____ low frustration tolerance___tearfulness ______hopelessness ______sense of impending doom____persistent negative thoughts ______reduced sex drive other:______

SUICIDAL IDEATION (thought of ending your own life): _____Y_____N

(if “yes”) _____thinking about suicide for relief from pain_____thinking about suicide as revenge ____thinking about suicide for opportunity for rebirth

CUTTING OR SELF INJURIOUS BEHAVIORS _____Y ______N

IF “yes” please describe method and tools______

______

If Yes: How Often?______

(If “yes”) ARE YOU WILLING TO “CONTRACT FOR SAFETY” (enter into an agreement not act on harming yourself or others and instead go to your local ER):

_____Y signature______DATE______

_____N signature______DATE______

ANXIETY: _____Y _____N

IF “yes” _____shortness of breath _____chest pain _____stomach/GI issues

_____IBS _____panic attacks ______obsessive behaviors _____compulsions

_____inability to relax _____racing thoughts _____ sweating _____fear of dying

____agoraphobia ______other phobias (describe)

____germophobia ______sleep disruption (describe)

____hypochondria _____fear of doctors _____social anxiety ______hot/flushing response ______pervasive repetitive worry thoughts

Other:______

______

TRAUMA HISTORY:

Sexual Trauma: ______Y ______N ______Past ______Present

If “yes” please describe if you are comfortable______

Physical Abuse _____Y _____N ______Past ______Present

Current safety concerns _____Y ____N

If “yes” please describe______

Emotional Abuse _____Y _____N ______Past ______Present

Current concerns r/t abuse for self and/or family (please describe):______

Adult child from dysfunctional family of origin (please describe – ie – Adult child of an alcoholic, etc.) ______

OTHER MENTAL ILLNESS (PLEASE CHECK):

_____Bipolar Disorder ______Schizophrenia ______Aspergers Disorder (past Diagnosis)______Autism Spectrum Disorder _____Borderline Personality Disorder

OTHER (please describe): ______

FAMILY HISOTRY OF MENTAL ILLNESS (please identify paternal/maternal history including medications and hospitalizations): ______

LEARNING DISABLITIES (diagnosis, treatment, medications):______

SUBSTANCE ABUSE:

SELF______Y______N

Please describe any substances you use:

Caffine______frequency______

Nicotine______frequency______

Alcohol______frequency______where do you drink?______who do you drink with?______

Marijuana______frequency______

Opiates______frequency______

IV Drugs______frequency______

Stimulants______frequency______

Other:______

Has anyone ever told you that substance use is problematic or might be a problem for you? Describe:______

______

______

Have you ever been hospitalized or gone to a rehabilitation program?___Y____N

Where?______

When?______

Do you use AA, NA, Alanon, or any support program?______Y______N

Do you have a sponsor?______

Does your spouse have a substance abuse problem?______Y______N

Describe:______

Does any family member have a substance abuse problem?______

______

LEGAL ISSUES/HISTORY: (please describe)______

______

HOBBIES:

Do you exercise?______Y______N

Describe any healthy activities you engage in:______

______

What do you like about these activities?______

______

______

TREATMENT GOALS:

What do you hope to learn and achieve during your time in therapy? ______

______How do you want to feel?______What do you want to change?______What do you like about yourself the most?______

______

What are your personality strengths?______

______

Client Signature______Date______

Clinician Signature:______Date______

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