Thomas L. Volker, Ed.D.
LifeSpan Behavioral Health, Inc.
Social Assessment
Name: _______________________________________
Age:___________________
What brought you to therapy?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
How were you referred you to Dr. Volker?
________________________________________________________________________
Family
Spouse/Partner: __________________________________________________________
Children/ages:
________________________________________________________________________
Important Family/Friends:
________________________________________________________________________
Important current family information:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Important family of origin information:
________________________________________________________________________
________________________________________________________________________
Medical
Family Physician:
________________________________________________________________________
Health problems now or in the past:
________________________________________________________________________
________________________________________________________________________
Current medications/dosage:
________________________________________________________________________
History of Physical/Sexual Abuse
As a child: ____physical abuse ____ sexual abuse ____emotional abuse ____ neglect
As an adult: ____ physical abuse ____sexual abuse/rape _____emotional abuse
Work and School History
Current Place of Employment:
________________________________________________________________________
Highest level of Education:
________________________________________________________________________
Problems at work:
________________________________________________________________________
History of Substance Use
DRUG
FREQUENCY
LAST USE
Alcohol:
Marijuana:
Cocaine:
Nicotine:
Narcotics/Pain medication:
Amphetamines:
Anxiety Medication:
Other: _________________________
I am concerned about my alcohol/drug use: Yes
No
I am concerned about alcohol/drug use in my family: Yes No
If yes, whom?
_______________________________________________________________________
Psychiatric/Counseling History
Past psychiatric hospitalizations:
________________________________________________________________________
Past suicide attempts:
________________________________________________________________________
I feel suicidal now:
Yes
No
If yes, rate on scale: 1(low) to 5(high)
My rating today: ___________________
Past mental health treatment: _______________________________________________
Mental Illness runs in my family: Yes
No
If yes, whom/diagnosis
______________
________________________________________________________________________
Past homicide attempts: ___________________________________________________
I feel homicidal now:
Yes
I have access to weapons: Yes
No
If yes, rate on scale: 1(low) to 5(high)
My rating today: _________________
No
If yes, weapon is _________________________
Legal Status
I have been arrested: Yes No If yes, reason, dates, outcome:
________________________________________________________________________
________________________________________________________________________
I am currently involved in court action: Yes No If yes, please explain:
________________________________________________________________________
________________________________________________________________________
Cultural Assessment
Please explain cultural beliefs that are important to you.
________________________________________________________________________
________________________________________________________________________
Religion/Spirituality
Please explain religious/spiritual beliefs that are important for you and/or your family.
________________________________________________________________________
_____________________________________________________________________________
Financial
Please explain any financial concerns for you and/or your family.
________________________________________________________________________
________________________________________________________________________
Strengths
Please explain your strengths:
________________________________________________________________________
________________________________________________________________________
Goals
Please explain goals for treatment:
________________________________________________________________________
________________________________________________________________________
Please complete the following section if the client is a child. If not, please sign below.
Child/Adolescent Addendum (Complete only if client is a child)
Please check concerns about your child/children:
_____adjustment
_____family problems _____parent/child _____depression
_____substance abuse _____anxiety
_____mood swings _____panic
_____learning problems _____behavior problems _____self esteem _____ psychotic
_____physical abuse _____sexual abuse _____sexual offender _____self-harm
_____harm to others _____problems at school _____ peer problems _____anger
_____loss _____abandonment _____trauma _____poverty _____witness violence
_____eating _____sleeping _____weight loss/gain _____hyperactive
_____lethargic
_____other, please explain:
______________________________________________________
Please explain any developmental problems:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Please explain any significant occurrence or change for your child:
________________________________________________________________________
________________________________________________________________________
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School: ________________________________________________________________
Grade:_____________ Teacher: ____________________________________________
School Counselor: ________________________________________________________
Grades are:
Signature:
Above average
average
below average
poor
_____________________________________Date: __________________