Client Name____________________________________________________
Date_______________________
Page __1__
PSYCHOSOCIAL HISTORY
PRESENTING PROBLEMS:______________________________________________________________________________________
____________________________________________________________________________________________________________
Duration:____________________________________________________________________________________________________
Additional information:_________________________________________________________________________________________
____________________________________________________________________________________________________________
CURRENT SYMPTOM CHECKLIST: (Rate intensity of symptoms currently present)
NONE = This symptom not present at this time
MILD = Impacts quality of life, but no significant impairment of day-to-day functioning
MODERATE = Significant impact on quality of life and/or day-to-day functioning
SEVERE = Profound impact on quality of life and/or day-to-day functioning
None
Depressed mood
( )
Appetite disturbance
( )
Sleep disturbance
( )
Elimination disturbance ( )
Fatique/low energy
( )
Psychomotor retardation( )
Poor concentration
( )
Poor grooming
( )
Mood swings
( )
Agitation
( )
Emotionality
( )
Irritability
( )
Generalized anxiety
( )
Panic attacks
( )
Phobias
( )
Obsessions/compulsions( )
Mild
( )
( )
( )
( )
( )
(
)
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
Moderate
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
Severe
None
( ) binging/purging
( )
( ) laxative/diuretic abuse ( )
( ) anorexia
( )
( ) paranoid ideation
( )
( ) circumstance symptom ( )
( ) loose associations
( )
( ) delusions
( )
( ) hallucinations
( )
( ) aggressive behaviors ( )
( ) conduct problems
( )
( ) oppositional behavior ( )
( ) sexual dysfunction
( )
( ) grief
( )
( ) hopelessness
( )
( ) social isolation
( )
( ) worthlessness
( )
Mild
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
Moderate
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
Severe
( )
( )
( )
( )
(
)
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
guilt
elevated mood
hyperactivity
dissociative states
somatic complaints
self-mutilation
weight gain/loss
concomitant condition
emotion trauma victim
physical trauma victim
sexual trauma victim
emotional trauma perp
physical trauma perpet
sexual trauma perpetra
substance abuse
other (specify)
None Mild Moderate
( ) ( )
(
)
( ) ( )
(
)
( ) ( )
(
)
( ) (
)
(
)
( ) (
)
(
)
( ) (
)
(
)
( ) ( )
(
)
( ) ( )
(
)
( ) (
)
(
)
( ) ( )
(
)
( ) ( )
(
)
(
) ( )
(
)
( ) ( )
(
)
( ) (
)
(
)
( ) ( )
(
)
( ) ( )
(
)
Severe
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
EMOTIONAL/PSYCHIATRIC HISTORY
( ) ( ) Counseling History
No
Yes
If yes, on _____ occasions. Longest treatment by _______________________for ____ sessions from ____/____ to ____/____
Provider Name
Mo Yr
Mo Yr
Prior provider name
________________
City
___________________
State
__________________
Phone
__________________
Diagnosis
__________________
Intervention/Modality
Beneficial?
_____________________________ _____________________
________________
__________ ________
__________________
___________________
__________________
_____________________________ _____________________
( ) ( ) Has any family member had counseling? If yes, who/why (list all):_______________________________________________________
No
Yes
___________________________________________________________________________________________________________________________
( ) ( ) Prior inpatient treatment for a psychiatric, emotional, or substance use disorder?
No
Yes
If yes, on ______occasions. Longest treatment at _________________________ from ____/____ to ____/____
Name of Facility
Inpatient facility name
__________________
__________________
City
State
Phone Diagnosis
_______ _______ _______ ______________
_______ _______ _______ ______________
Mo
Yr
Mo
Intervention/Modality
______________________
______________________
Yr
Beneficial?
___________________
___________________
( ) ( ) Has any family member had inpatient treatment for a psychiatric, emotional, or substance use disorder? If yes,
No
Yes
who/why (list all): ____________________________________________________________________________________________________________
( ) ( ) Current Medications: If yes:
No
Yes
Medication
____________
____________
____________
____________
____________
____________
Dosage
______
______
______
______
______
______
Frequency
_____________
_____________
_____________
_____________
_____________
_____________
Start date
_____________
_____________
_____________
_____________
_____________
_____________
Physician
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
Client Name_____________________________________________________ Date_____________________
Page__2__
FAMILY HISTORY
FAMILY OF ORIGIN
Present during childhood:
Present
Present
Not
Entire
part of
present
Childhood childhood at all
Mother
( )
( )
( )
Father
( )
( )
( )
Stepmother ( )
( )
( )
Stepfather ( )
( )
( )
Brother(s) ( )
( )
( )
Sister(s)
( )
( )
( )
Other
( )
( )
( )
(specify)
____________________________________
Parents’ current marital status:
( ) married to each other
( ) separated for ____ years
( ) divorced for ____ years
( ) mother remarried ____ times
( ) father remarried ____ times
( ) mother involved with someone
( ) father involved with someone
( ) mother deceased for ____ years
age of client at mother’s death ____
( ) father deceased for ____ years
age of client at father’s death ____
Describe parents:
Father
Full Name__________________
Occupation_________________
Education__________________
General Health______________
Mother
_______________________
_______________________
_______________________
_______________________
Describe childhood family experience:
( ) outstanding home environment
( ) normal home environment
( ) chaotic home environment
( ) witnessed physical/verbal/sexual abuse toward others
( ) experienced physical/verbal/sexual abuse from others
Special circumstances in childhood:______________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
IMMEDIATE FAMILY
Marital status:
( ) single, never married
( ) engaged ____ months
( ) married for ____ years
( ) divorced for ____ years
( ) separated for ____ years
( ) divorce in process ____ months
( ) live-in for ____ years
( ) ____prior marriages (self)
( ) ____ prior marriages (partner)
Intimate relationship:
( ) never been in a serious relationship
( ) not currently in relationship
( ) currently in a serious relationship
Relationship satisfaction:
( ) very satisfied with relationship
( ) satisfied with relationship
( ) somewhat satisfied with relationship
( ) dissatisfied with relationship
( ) very dissatisfied with relationship
List all persons currently living in client’s household:
Name
Age
Sex
Relationship to Client
________________ ___
___
_________________
________________ ___
___
_________________
________________ ___
___
_________________
________________ ___
___
_________________
________________ ___
___
_________________
List children not living in same household as client:
_________________ ___
___
_________________
_________________ ___
___
_________________
_________________ ___
___
_________________
Describe any past or current significant issues in intimate relationships: __________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Describe any past or current significant issues in other immediate family relationships: ______________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
MEDICAL HISTORY (check all that apply for client)
Describe current physical health: ( ) Good ( ) Fair ( ) Poor
______________________________________________________
List any known allergies:_________________________________
Is there a history of any of the following in the family:
( ) tuberculosis
( ) heart disease
( ) birth defects
( ) high blood pressure
( ) emotional problems
( ) alcoholism
( ) behavior problems
( ) drug abuse
( ) thyroid problems
( ) diabetes
( ) cancer
( ) Alzheimer’s disease/dementia
( ) mental retardation
( ) stroke
( ) other chronic or serious health problems ____________
______________________________________________
List any abnormal lab test results:
Date __________ Result _____________________
Date__________ Result _____________________
Describe any serious hospitalization or accidents:
Date ________ Age ____ Reason_____________________
Date_________ Age ____ Reason _____________________
List name of primary care physician:
Name___________________________ Phone________________
List name of psychiatrist: (if any)
Name___________________________ Phone________________
Client Name_________________________________________________________ Date _________________
Page __3__
SUBSTANCE USE HISTORY (check all that apply for patient)
Family alcohol/drug abuse history:
(
(
(
(
(
) father
( ) stepparent/live-in
) mother
( ) uncle(s)/aunt(s)
) grandparent(s) ( ) spouse/significant other
) sibling(s)
( ) children
) other______________________
Substance use status:
(
(
(
(
(
(
) no history of abuse
) active abuse
) early full remission
) early partial remission
) sustained full remission
) sustained partial remission
Substances used:
(complete all that apply)
( ) alcohol
( ) amphetamines/speed
( ) barbiturates/owners
( ) caffeine
( ) cocaine
( ) crack cocaine
( ) hallucinogens (e.g. LSD)
( ) inhalants (e.g. glue, gas)
( ) marijuana or hashish
( ) nicotine/cigarettes
( ) PCP
( ) prescription__________
( ) other_______________
First use age
______
______
______
______
______
______
______
______
______
______
______
______
______
Last use age
______
______
______
______
______
______
______
______
______
______
______
______
______
Treatment history:
Consequences of substance abuse (check all that apply):
(
(
(
(
(
(
(
(
(
(
) outpatient (age(s)_________________
) inpatient (age(s)__________________
) 12-step program (age(s) ___________
) stopped on own (age(s) ____________
) other (age(s)_____________________
Describe:________________________
Current Use
(Yes/No)
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
Frequency
________
________
________
________
________
________
________
________
________
________
________
________
________
Amount
______
______
______
______
______
______
______
______
______
______
______
______
______
) hangovers
( ) withdrawal symptoms
( ) sleep disturbance
( ) binges
) seizures
( ) medical conditions
( ) assaults
( ) job loss
) blackouts
( ) tolerance changes
( ) suicidal impulse
( ) arrests
) overdose
( ) loss of control amount used ( ) relationship conflicts
) other____________________________________________________________________________
DEVELOPMENTAL HISTORY (check all that apply for a child/adolescent client)
Problems during
Mother’s pregnancy:
( ) none
( ) high blood pressure
( ) kidney infection
( ) German measles
( ) emotional stress
( ) bleeding
( ) alcohol use
( ) drug use
( ) cigarette use
( ) other
Birth:
( ) normal delivery
( ) difficult delivery
( ) cesarean delivery
( ) complications________________
Birth weight ____ Lbs. ____ oz.
Infancy:
( ) feeding problems
( ) sleep problems
( ) toilet training problems
Childhood health (enter age occurred)
( ) chickenpox _________
( ) lead poisoning _____
( ) German measles _____
( ) mumps ___________
( ) red measles _________
( ) diphtheria _________
( ) rheumatic fever ______
( ) poliomyelitis________
( ) whooping cough ______
( ) pneumonia ________
( ) scarlet fever_________
( ) tuberculosis________
( ) autism
( ) mental retardation
( ) ear infections
( ) asthma
( ) allergies to ____________________________________
( ) chronic, serious health problems___________________
______________________________________________
Delayed developmental milestones
(check only milestones that did not occur at expected age):
Emotional/behavior problems
(check all that apply):
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
) sitting
( ) controlling bowels
) rolling over
( ) sleeping alone
) standing
( ) dressing self
) walking
( ) engaging peers
) feeding self
( ) tolerating separation
) speaking words
( ) playing cooperatively
) speaking sentences
( ) riding tricycle
) controlling bladder
( ) riding bicycle
) other_______________________________________
) drug use
) alcohol abuse
) chronic lying
) stealing
) violent temper
) fire-setting
) animal cruelty
) hyperactive
) assaults others
) disobedient
(
(
(
(
(
(
(
(
(
(
) repeats words of others
) not trustworthy
) hostile/angry mood
) indecisive
) immature
) bizarre behavior
) frequently tearful
) self-injurious threats
) frequently daydreams
) lack of attachment
Social Interaction (check all that apply):
Intellectual/academic functioning (check all that apply):
(
(
(
(
( ) normal intelligence
( ) high intelligence
( ) learning problems
) normal social interaction
) isolates self
) very shy
) alienates self
(
(
(
(
) inappropriate sex play
) dominates others
) associates with acting-out
) other ________________
( ) authority conflicts
( ) attention problems
( ) underachieving
(
(
(
(
(
(
(
(
(
) distrustful
) extreme worrier
) self-injurious acts
) impulsive
) easily distracted
) poor concentration
) often sad
) breaks things
) other______________
__________________
( ) mild retardation
( ) moderate retardation
( ) severe retardation
Current or highest education level _______________________________________________
Describe any other developmental problems or issues: ____________________________________________________________________________________
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
Client Name_________________________________________________________Date____________________
Page__4__
SOCIO-ECONOMIC HISTORY (check all that apply for client)
Living situation:
Social support system:
(
(
(
(
) housing adequate
( ) supportive network
) homeless
( ) few friends
) housing overcrowded ( ) substance-use-based friends
) dependent on others
( ) no friends
for housing
( ) distant from family of origin
( ) housing dangerous/deteriorating
( ) living companions dysfunctional
Employment:
Military history:
(
(
(
(
(
(
(
( ) never in military
( ) served in military – no incident
( ) served in military – with incident
__________________________
__________________________
__________________________
) employed and satisfied
) employed but dissatisfied
) unemployed
) coworker conflicts
) supervisor conflicts
) unstable work history
) disabled:______________
Sexual history:
(
(
(
(
(
) heterosexual orientation
) homosexual orientation
) bisexual orientation
) currently sexually active
) currently sexually satisfied
Financial situation:
(
(
(
(
(
) currently sexually dissatisfied
) age first sex experience _____
) age first pregnancy/fatherhood _____
) history of promiscuity age ____to ____
) history of unsafe sex age ____to ____
(
(
(
(
(
) no current financial problems
) large indebtedness
) poverty or below-poverty income
) impulsive spending
) relationship conflicts over finances
Additional information:__________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Legal history:
(
(
(
(
(
(
Cultural/spiritual/recreational history:
) no legal problems
Cultural identity (i.e. ethnicity, religion):_____________________________________________________
) now on parole/probation
______________________________________________________________________________________
) arrest(s) not substance-related
Describe any cultural issues that contribute to current problem:__________________________________
) arrest(s) substance-related
______________________________________________________________________________________
) court ordered this treatment
______________________________________________________________________________________
) jail/prison ______ time(s)
Total time served:___________
Describe last legal difficulty:____________________________________________________________________________________________
___________________________________________________________________________________________________________________
SOURCES OF DATA PROVIDED ABOVE: ( ) Client self-report for all. ( ) A variety of sources (if so, check appropriate sources below):
Presenting Problems/Symptoms
Family History
Developmental History
( ) client self-report
( ) client’s parent/guardian
( ) other (specify)__________________
( ) client self-report
( ) client’s parent/guardian
( ) other (specify)_______________
( ) client self-report
( ) client’s parent/guardian
( ) other (specify)_______________
Emotional/Psychiatric History
Medical/Substance Use History
Socioeconomic History
( ) client self-report
( ) client’s parent/guardian
( ) other (specify)__________________
( ) client self-report
( ) client self-report
( ) client’s parent/guardian
( ) client’s parent/guardian
( ) other (specify)_______________ ( ) other (specify)______________