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________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Treatment plan ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Resources ________________________________________________________________________ 11/2010