ADULT PSYCHOSOCIAL ASSESSMENT
The following necessary information will help make your first session most productive. Please ensure that all therapy participants (18 years & older) sign a Patient Agreement
form. If you are court-mandated to receive counseling, bring in the court order or case plan. Please bring all documents to the first session.
Please PRINT and fill out this form COMPLETELY.
Date of assessment:
DEMOGRAPHICS
Last Name
Date of Birth
Age
Residence Address
First
Middle
Social Security Number
Driver License Number
City
Telephone (Cell)
State
(Home)
Zip Code
(Work)
Marital Status:
State
Email
Gender:
Single
Married
Separated
Remarried
Partnered
Widowed
Divorced
Male
Female
PERSONAL HISTORY
Why are you seeking treatment at this time?
STAFF NOTES
What do you need help with?
(Check all that apply)
Anxiety
ADHD
Employment/school
Depression
Mood Swings
Physical/medical
Relationship problems
Grief/Death
Psychosis
Extramarital Affair
Abuse
Children/parenting
Addiction
PTSD/Trauma
Other
MENTAL HEALTH
Have you had any of the following within the past 90 days?
(Check all that apply)
Suicidal thoughts
Depression
Impulsive
Suicide attempts
Anxiety
Panic/phobia
Self injury
Mood swings
Hospitalization
Obsessive/intrusive thoughts
Death in family
Poor sleep patterns
Thoughts of harming others
Paranoia/Delusions
Weight gain/loss
Violence
Racing thoughts
Hallucinations
Santa Rosa Counseling Center
5642 Jones Street, Milton, Florida 32570
Office (850) 626-7779 Fax (850) 626-7171
santarosacounselingcenter.com
REV 11/20/2014
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Yes
Have you ever been in counseling before?
Dates
Counselor
No
STAFF NOTES
Reason for discontinuing/discharge
Starting with most current, please list current and past mental/behavioral health medications:
Medication
Dose
Reason
Doctor
Still taking?
Have you ever taken mental/behavioral health medications in the past?
If yes, please list:
Yes
No
Have you ever been admitted into a hospital for mental/behavioral health?
Yes
No
Yes
No
Yes
No
Date(s)
Location
Is there any family history of mental health problems or suicide (attempts)?
If yes, please explain:
MEDICAL
Who is your primary care physician?
Doctor
Address/Location
Do you currently have any medical problems?
Please list all symptoms and medications:
Does your physical pain cause mental health issues?
Yes
No
Have you recently experienced any appetite changes?
Yes
No
Have you recently had a gain or loss of over 10 lbs.?
Yes
No
Yes
No
Yes
No
Have you been arrested in the past two years?
Yes
No
Are you involved with a DCF/FFN case or investigation?
Yes
No
What are your sleep patterns?
EMPLOYMENT/EDUCATION
Are you currently employed?
Employer
Length of employment
What is your highest level of education completed?
Are you currently a student?
School
Program/Grade level
LEGAL
Adult Psychosocial Assessment
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Are you court ordered for services?
Yes
No
Are you currently assigned to a probation officer or caseworker?
Yes
No
Yes
No
Have you ever used or are you currently using any substances?
Yes
No
Have you ever felt guilt or remorse about your substance use?
Yes
No
Have you ever tried to stop and have been unsuccessful?
Yes
No
STAFF NOTES
If yes:
Name
Phone
Will you require progress reports for legal authorities?
SUBSTANCE USE
Date
Circumstance
Please describe your history of substance use below:
Substance Type
Method of use and
amount
Frequency of Use
Age of
first use
Use in last
48 hours
Age of
last use
Yes
No
Used in last
30 days
Yes
No
Alcohol
Barbiturates
Cocaine/Crack
Hallucinogens
Heroin/Opiates
Inhalants
Marijuana
Methadone
Methamphetamine
Nicotine
Prescription pills †
Steroids
Other
† Circle
all that apply: Lortab | OxyContin | Darvocet | Percocet | Xanax | Soma | Valium Other: ________________________________
An additional section may be completed during your session if substance use or abuse is indicated.
FAMILY HISTORY
Who were you raised by?
Describe your relationship with your parents/caregivers:
How many siblings do you have?
Describe names, ages and respective relationships with your siblings:
Are you living with a spouse or partner at present?
Yes
No
Yes
No
Describe your relationship with your spouse or partner:
Do you have any children?
Describe names, ages, and respective relationships with your children:
Adult Psychosocial Assessment
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STAFF NOTES
SOCIAL/SUPPORT SYSTEM
Describe your leisure/recreational activities:
Is your current home environment safe?
Yes
No
If no, describe the details:
Who is your support system?
What do you hope to gain out of treatment?
Please list all family members and ages that will be involved in treatment:
Patient Name
Patient Signature
PROVIDER SIGNATURE
K. ALESIA WILLIS, LMFT, LMHC
SUE GESSLER, LMHC
BRIAN E. WILLIS, LMHC
BRITTANY PAQUETTE, LMHC
MELISSA D. GARNER, LMHC
Adult Psychosocial Assessment
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