PSYCHOSOCIAL ASSESSMENT
Name: _______________________
Date: ________________
Preferred method of communication: TEXT
EMAIL
OTHER (please specify) ________________________
Emergency Contact and Contact’s Phone Number: ________________________________________________________
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Why are you seeking therapy?
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What are your goals in therapy?
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If you woke up tomorrow and your life was perfect, what would your life be like?
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If I was a fly on the wall when you were growing up, what would I see?
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Education and Occupation:
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School currently attending, if applicable:
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Highest grade completed:
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Occupation and employment history:
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Occupational skills / training:
Family History:
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Family’s current and past psychiatric history:
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Family’s and client’s physical / sexual / emotional abuse history:
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Family’s substance use / abuse history:
What does your support system look like? Who is involved and what is the relationship?
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What is your substance use history?
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What is your mental health history (including any diagnosis)?
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Do you have events or time periods in your life that you consider traumatic?
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Do you have any significant medical issues?
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What medications are you on? Do you take them as prescribed? Are there any side effects?