INITIAL PSYCHOSOCIAL ASSESSMENT QUESTIONNAIRE

Client:_____________________________________________ Intake Date: ________________________

Date of Birth: ______- ______ – ______ Age: _______ Sex: M F Race: __________________

Interviewer: __________________________________________________

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Current Family/Support System: (Current family household composition and relationships)

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Presenting Problem: Short statement about immediate concern, current situation, and by whom referred. (List symptoms/onset/duration/precipitating events/current stressors)

Client Interview: ________________________________________________________________________________________

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Current Level of Functioning: (Assess sleep/appetite/mood/energy/substance use)

Sleep___________________________________________________________________________________

Appetite_________________________________________________________________________________

Energy Level_____________________________________________________________________________

Attention_________________________________________________________________________________

Mood___________________________________________________________________________________

Hallucinations/Delusions____________________________________________________________________

Other___________________________________________________________________________________________________________________________________________________________________________

Risk Assessment:

Suicidal Ideation

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Homicidal Ideation

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Safety Plans

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Mental Health Treatment History:

History of Problems/Age at First Diagnosis: No Yes

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Past Outpatient Treatment: No Yes

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Past Inpatient Treatment: No Yes

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Family History of Mental Health treatment/Diagnosis: No Yes

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Relevant History:

Family Issues: No Yes

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Physical Abuse: No Yes

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Sexual Abuse: No Yes

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Other Trauma: No Yes

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Educational History:

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Medical History:

Present Physical condition:

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History of Illness, Injury, or Surgery: No Yes

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Medications: (Six month history of prescribed and over-the-counter medication including dose prescriber/when taken/illness/results)

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Legal History:

Current or Pending Legal Involvement: No Yes

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Past Legal Involvement: No Yes

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Alcohol and Drug History and Current Use:

(Include all drugs ever abused/onset of use, average quantity and frequency/last use/route of administration)

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Employment History:

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Summary and Intervention Recommendations:

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TREATMENT GOAL:

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TREATMENT ACTION STEPS:

1. __________________________________________________________________________________

2. __________________________________________________________________________________

3. __________________________________________________________________________________

Clinician Signature: ______________________________________________ Date: __________________

(rev. 8/18) 1