In the following sections, two templates for psychosocial assessment will be presented. The first template is a shorter form, containing a less comprehensive approach to covering all of the domains in each of the time frames. It is closer to what a clinician in private practice is likely to use when conducting and recording an initial assessment. 

The second template, presented in the next section, will consist of a very comprehensive form, focusing on the four anchor points and three time frames we addressed earlier. This template is most appropriate when a full and thorough psychosocial assessment is warranted. It includes all the aspects that researchers and practitioners have identified as essential elements in the psychosocial assessment process.

Both of these templates are designed to represent a best practices approach to the assessment process. Both are designed to gather the range of information that is needed to formulate good treatment decisions. In fact, the two forms will gather much of the same information, while placing slightly different emphasis on certain parts of that information and recording the information in different formats.

The template can be used for a narrative assessment, or in conjunction with standardized or commercial products. It can also be used with graphic representations to ensure that all elements are addressed prior to development of the treatment plan. Clinicians should feel free to use these templates as a starting point that can be modified to suit their own circumstances in practice.

 

The concise form begins on the next page, with explanation on each section to follow.

 

 

Client Assessment Form

 

Client Name:                                                        Assessment Date:                            _________ 

Address:                                                               Town/State/Zip:                                                  

Home Phone:                                                        Work Phone:                                                      

Emergency Contact:                                             Contact Phone:                                                  

Name of PCP:                                                        PCP Address:                                                    

Insurance Plan:______________________           Insurance ID#:                                                  

Parties in attendance/relationship to client: 

 

 

Presenting Problem (Chief complaint/concern; precipitating event; signs and symptoms; history of problems)

 

 

 

Symptom Inventory / Mental Status (Current Ratings:  0=None   1=Mild   2=Moderate   3=Severe)

__Generalized Anxiety ....... __Weight change.......__Suspiciousness

__ Phobias.......__Impaired memory.......__Paranoid ideation

__ Panic Attacks.......__Irritability.......__ Bizarre Behaviors

__Depersonalization.......__ Anger control problems.......__Delusions

__Obsessions/Compulsions.......__ Aggressiveness.......__Confused

__Depression...__Impulsiveness ...__Tangential/Circumstantial thinking

__Psychomotor retardation.......__Distractibility.......__Agitation

__Low energy.......__Focus/concentration problems.......__ Dissociation

__Fatigue.......__Negative Self Image.......__ Hallucinations

__Withdrawal.......__Disorientation.......__ Loose Associations

__Hopelessness.......__Mania/Hypomania.......__ Flight of Ideas

__Sleep disturbance.......__Tremors.......__Intrusive thoughts

 Mood:    __ Normal   __Anxious   __Depressed   __Irritable   __Euphoric  __Expansive __Dysphoric __Calm

Affect:   __Normal   __Unconstrained   __Blunted/Restricted   __Inappropriate   __Labile __Flat

Behavior: __Normal   __Aggressive   __Impulsive  __Angry   __Oppositional  __Agitated  __Explosive

Symptom Inventory / Mental Status (Current Ratings:  0=None   1=Mild   2=Moderate   3=Severe)

Eye Contact: __Normal  __Fleeting  __Avoidant   __Staring  __Other 

Facial Expression: __Responsive  __Flat   __Tense   __Anxious  __Sad  __Angry

Attitude Toward Clinician: __Normal/Cooperative  __Uninterested    __Passive  __Guarded  __Dramatic  __Manipulative  __Suspicious   __Rigid  __Sarcastic __Resistant  __Critical  __Irritable  __Hostile  __Threatening

Appearance:  __Normal   __Disheveled   __Unclean   __Inappropriate   __Unhealthy looking 

Insight:  __Good   __Impairments in insight        

Decision Making: __Good  __Impairments in decision making       

Reality Testing: __Good   __Impairments in reality testing     

Judgment:  __Good  __Impairments in judgment      

Interpersonal Skills:  __Normal  __Impaired    

Intellect: __Average or above  __Impaired    

 

Impairments caused by symptoms/mental status problems: 

 

 

Comments on symptoms/mental status problems: 

 

 

Risk Assessment

Suicide     __None  __Ideation  __Intent  __Plan  __Means  __Attempt

Explain:

Homicide __None  __Ideation  __Intent  __Plan  __Means  __Attempt

Explain:

Physical/sexual abuse:          _ _Denies           ___Yes 

Explain: 

Child/elder neglect or abuse:_ _Denies           ___Yes 

Explain: 

 

• If risk of any of the above exists, client ___can ___cannot agree to a contract not to harm

___self           ___others              ___both

 

Domestic Violence   (1=Client   2=Partner   3=Both)

Have you (your partner)?                                                                                 .................................................................... ........Current                        Past

Slapped, kicked, pushed, choked, or             ...___                          .     ___      ....................... punched the other?                                

Forced or coerced the other to have sex?    .. ___                               ___

Threatened the other with a knife or gun?  ..  ___                               ___     

Made the other afraid that they could be    ..  ___                               ___                       physically hurt?                             

Verbal threats or abuse, ongoing, frequent    ___                                ___                           

                                                   

Comments:

 

 

Drug/ETOH Use (Please rate amount and frequency, present and past: e.g., 2B = moderate, infrequent)

(Amount of use ratings: 0=No use   1=Light or limited use   2=Moderate use   3=Heavy use    4=Extreme use)      (Frequency of use modifier: A=Almost never   B=Infrequent / Occasional   C=Regular, not constant   D=Constant)

 

...................................................Current use.........................Past use                                  

Alcohol..........................................___                                     ___

Marijuana.....................................___                                     ___

Cocaine.........................................___                                     ___

Other (list): _____________...........___                                     ___

Other (list): _____________...........___                                     ___

Other (list): _____________...........___                                     ___

Other (list): _____________...........___                                     ___

 

Substance Use Problem Effects    (Ratings:  0=None    1=Mild     2=Moderate    3=Severe)

Current use                     Past use

Used alcohol/drugs more than intended                                                             ___                                     ___

Spent more time using/drinking than intended                                                  ___                                     ___

Neglected some usual responsibilities because of alcohol or drugs                ___                                     ___

Wanted or needed to cut down on drinking or drug use in past year             ___                                     ___

Someone has objected to client’s drinking/drug use                                         ___                                     ___

Preoccupied with wanting to use alcohol or drugs                                             ___                                     ___

Used alcohol or drugs to relieve emotional discomfort,                                   ___                                     ___

such as sadness, anger, or boredom

Comments:

 

Prior counseling/Psychiatric history (Inpatient / outpatient; dates (if known); providers; results)

 

Medical Status (Include current and past medical conditions, last visit to MD, and current and past medications)

 

 

Psychosocial problems/ Stressors (Current Ratings:  0=None   1=Mild   2=Moderate   3=Severe)

 

___Work / career                 (Explain): _____________________________

___Financial                        (Explain): _____________________________

___Housing                          (Explain): ____________________________

___Legal                               (Explain): ____________________________

___Health                             (Explain): ____________________________

___Family                            (Explain): ____________________________

___Other                               (Explain): ___________________________

Coping Resources (Include coping skills/deficits, social supports, hobbies, exercise, nutrition, etc.)

 

 

Diagnostic Impressions/Therapeutic Recommendations:

 

Dx:  _________________________________________     Code: _________

Dx::  _________________________________________    Code: _________

Dx:__________________________________________     Code: _________

Dx: _________________________________________     Code: _________

Dx::_________________________________________     Code: _________

Dx::_________________________________________     Code: _________

 

Disposition/Referral

 

 

___________________________                                                                             

                    Signature                                                                         Date

 

 

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