Adult Psychosocial Assessment Questionnaire Name: Date: Date of

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Adult Psychosocial Assessment Questionnaire
Name: _______________________________________________
Date of Birth: ______________
Sex: _________
Date: _____________________
Social Security Number: __________________
Directions: Please answer the following questions as fully as possible. (Please note that you will not be discriminated
on based on your responses. You may choose not to answer a question if you are not comfortable disclosing the information. Please be aware that
accurate assessment and appropriate treatment is in part based on what you are willing to share about yourself.)
Present Problems or Stressors
“In the recent months, I have worried a lot about or have had”: (Please circle all that apply)
Marital issues
Parent/child issues
Health issues
Substance Abuse
Job issues
Abuse/Neglect
Money concerns
Legal Troubles
Other: ____________________________
Symptoms (Please circle all that apply)
Sleep changes/problems
Decreased energy
Decreased concentration
Decreased motivation
Change in appetite
Suicidal feelings
Increased anxiety
Other: ________________
Suicidal/Homicidal Ideation
Have you ever attempted to commit suicide or homicide in the past? ______
If yes, describe: __________________________________________________________________________
Is there a history of suicide in your family? ____If yes, describe _____________________________________
Have you ever inflicted burns, cuts or other wounds to yourself? ___ If yes, describe ____________________
Do you currently have thoughts to harm yourself or others? ________________________________________
Recent Losses (Please circle all that apply)
Family Member
Health
Employment
Housing
Significant other
Psychiatric History
Please list any previous outpatient counseling and evaluations, include any chemical dependency services:
Counselor ______________________________________
Length of time ___________________________________
Reason_______________________
Dates ________________________
Counselor______________________________________
Length of time __________________________________
Reason_______________________
Dates ________________________
Have you ever been admitted to the hospital for mental health or addiction issues? ____________
Place __________________________________________
Length of time ___________________________________
Reason ______________________
Dates ________________________
Place __________________________________________
Length of time ___________________________________
Reason ______________________
Dates ________________________
Other
Name of current psychiatrist, if any __________________________________________________
List all medications you have taken in the past for anxiety, depression, and/or sleep:
_______________________________________________________________________________________
_______________________________________________________________________________________
Medical Information
Describe any current medical condition(s) ________________________________________________________
Are you currently on any medication ________ Who is/are your doctor(s): ______________________________
Please list any medication, dosage, and how often you take it:_________________________________________
_________________________________________________________________________________________
Are you currently taking any herbs, if yes please list them____________________________________________
Has it been more than a year since your last physical exam, including a blood test? _____
Number of Children _____ Number of Pregnancies: ____ Are you or your partner currently pregnant: ______
Do you have any allergies? If so, please list them___________________________________________________
Please list any previous health problems, surgeries, and hospitalizations___________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________
Substance Use / Problem Behavior History:
Describe your current usage or usage within the past year of alcohol, drugs, caffeine, tobacco, pornography, gambling,
and prescription pain medication (Please list the substance, the amount, the frequency, the age of 1st use, the age regular
use started, and the date of last use). ________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
What is your drug of preference? __________________________________________
Have you experienced a recent increase in use of alcohol and/or other drugs? _______
Do you see your current usage as a problem? _________________________________
Have you ever attended Alcoholics or Narcotics Anonymous or other self-help meetings? ___________________
Please describe any previous problems with drugs or alcohol __________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Describe any significant family history of substance abuse____________________________________________
__________________________________________________________________________________________
Nutrition
Have your eating habits changed recently? Yes No
If yes, please describe:_____________________________
Has your weight fluctuated more than +/- 10lbs. over the previous year? Yes No
Do you often eat when depressed, bored, or angry? Yes No
If yes, please describe: _____________________________________________________________________
Do you ever self-induce vomiting? Yes No
Do you ever binge eat or feel your eating is out of control? Yes No
If yes, describe: ___________________________________________________________________________
If you use laxatives, water pills, or diet medications, how often do you use them? ________________________
Legal/Criminal History (Please explain all that apply)
Charges as a minor__________________________________________________________________________
Charges presently___________________________________________________________________________
Past Charges ______________________________________________________________________________
Arrests (How many) ______Convictions (How many) ____ Incarcerations (How many) ______
Are you currently on Parole or Probation (if so, for what charge):______________________________________
Do you have any child custody problems? ______ If so, please explain: ______________________________
_________________________________________________________________________________________
Developmental History
List members of your family that you grew up with and how you got along with each one.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
What was your birth order? ____of ____ children
Who primarily raised you? ____________________________
How would you describe your childhood? _________________________________________________________
What were you like as a child (include friends, school, hobbies, and personality)? __________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Were there any unusual or traumatic experiences for you as a child? (Please list the age
that it occurred and the event that occurred)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
What is your sexual orientation? ____ Heterosexual _____ Homosexual ______ Bisexual
Support System
Who can you count on for support? (circle all that apply)
Parents
Spouse
Siblings
Employer
Church
Pastor
Therapist
Neighbor
Family
Close Friend
Co-workers
Doctor
Self-help
Community Services
Who are you currently living with? ______________________________________________________________
Financial Situation:
Describe briefly your financial situation _______________________________________________________________
Financial History/Information (must complete and provide verification if you are requesting sliding fee for payment of treatment)
Present monthly household income: (all sources) _______________
Debt owed:
Amount of Assets: ______________
Restitution _________ Fines ____________ Medical ______________ Loans _____________
Attorney ___________ Credit Cards ___________ Collections____________ Other _________
Marital History (if applicable)
Any you currently married or in a serious relationship: ______
What was the date of your current marriage or how long have you been together? _________
Name and age of spouse
_________________________________________________________________________
Any children from this relationship? If so, please list:______________________________________________
Tell me about your current relationship (include communication patterns, problems, sexual relations, etc……)
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Previous marriage? Yes No How many ______ Date of divorce/separation_______________
Please list that name, ages and the custodial parent of each of your children. How do
you get along with each one? ___________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Religious/Cultural Factors
Please list any religious or cultural issues that might influence your treatment or that are important to you:
__________________________________________________________________________________________________
___________________________________________________________________________________________
What, if any are your religious and/ or spiritual practices? _____________________________________________
Work History
Are you employed _____ full time, _____ part time, ______ disabled or _____unemployed?
If employed, describe your current job or career: ___________________________________________________
If you could have any job/career, what would you choose and why? _____________________________________
__________________________________________________________________________________________
Describe your relationship with co-workers _______________________________________________________
Describe your job performance _________________________________________________________________
Have you ever been fired? Yes No
If yes, explain ________________________________________________
How many jobs have you had in the past five years? ____ Were you ever in the military? If so, describe ________
Educational History
Do you have GED or diploma? _____ Highest level of education completed? _____
How were your grades? __________________Did you receive special education services? ____
Have you attended college or vocational school? If so, where/when _____________________________________
Are you currently in school or college? Yes No If yes, where? ________________________________________
Feelings/ Trust Issues
Do you have difficulty showing or sharing feelings? ______ Do you have difficulty with anger? _______
Do you have difficulty trusting others? ______ Do you have difficulty with authority? ________
Describe any difficulties you indicated____________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Family
Would it be beneficial for any members of your family to be involved in your treatment? ___________________
If yes, explain ______________________________________________________________________________
Is there anything else you feel that I need to know about you? _____
If yes, please explain:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
FOR STAFF
Behavioral Notes____________________________________________________________________________
Mental Status Notes __________________________________________________________________________
Comprehension _____________________________________________________________________________
Summary __________________________________________________________________________________
S _________________________________________________________________________________________
O ________________________________________________________________________________________
A ________________________________________________________________________________________
P _________________________________________________________________________________________
Diagnosis if applicable________________________________________________________________________
________________________________________________________________________
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Treatment plan
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Resources
________________________________________________________________________
11/2010
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