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ERK4499 - SECTION 7: THE CONCISE PSYCHOSOCIAL ASSESSMENT

 

Section 7: The Psychosocial Assessment

Well designed psychosocial assessments are not necessarily expansive in length or detail. Fully inclusive, comprehensive psychosocial assessments are not for everyone. They are necessary for only about 5% of the client population. These individuals have complex issues across one or more domains of functioning, requiring more detail about particular areas where the complex problems exist. For the remaining 95% of clients, a less comprehensive format is often sufficient.

A comprehensive psychosocial assessment is more often the model used in institutional and public organizational settings, while the more concise model is more likely to be used in most private practice settings.

In order for the clinician to function at the optimal level of professional practice, he/she must have the knowledge and the professional judgment to know when to use a more comprehensive assessment tool, and when a shorter, less comprehensive assessment is appropriate. For more information on this subject, as well as a more thorough study of the psychosocial assessment process as a whole, trainees may want to examine yourceus.com’s course, Psychosocial Assessment: A Comprehensive Overview for Mental Health Clinicians.

This course will first present a template for the less comprehensive assessment form, with brief explanations of what has been included and why. There is considerable overlap between this template and the more comprehensive form, but the more comprehensive form has a couple of sections that are better able to gather and record the complications of highly complex cases. Later in this chapter, these sections will be presented with explanation.

In general terms, the psychosocial assessment is designed to be an organized process or system of gathering information related to the person’s history, strengths, problems and challenges, resources, and future plans. They form the starting point for all professional interventions - the better the assessment, the easier it is to target the right interventions and therefore improve client outcomes.

As we present the concise client assessment form, you will see these items contained in different sections.

 

CONCISE CLIENT ASSESSMENT FORM

Client Name:_______________________ Date of birth: _________________
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 (0=None 1=Mild 2=Moderate 3= High 4-Severe 5-Extreme )

__Generalized Anxiety   __ Phobias   __ Panic Attacks   __Depersonalization __Dissociation   __Obsessions/Compulsions   __Depression   __Psychomotor retardation   __Mania/Hypomania   __Focus/concentration problems   __Agitation __Low energy   __Fatigue   __Withdrawal   __Hopelessness   __Sleep disturbance   __Weight change   __Impaired memory   __Irritability   __ Anger control problems   __Aggressiveness Impulsiveness   __Distractibility   __Negative Self Image   __Disorientation   __Confusion   __ Flight of Ideas  __Tremors   __Delusions   __Tangential/Circumstantial thinking  __Suspiciousness  __Loose Associations  ___Intrusive thoughts  __Paranoid ideation __ Hallucinations   __ Bizarre Behaviors


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

Social Relating / Executive Functioning (0=None 1=Mild 2=Moderate 3= High 4-Severe 5-Extreme)

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?                 ___ ___
Repeatedly used words, yelled, or screamed in a way                        ___ ___
that frightened, threatened, put down, or made the other feel rejected?

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= High 4-Severe 5-Extreme )
                                                                                              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:


Important Family History



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:




DSM-5 Diagnosis

Diagnosis: _________________________________________________ Code: ____________
Diagnosis: _________________________________________________ Code: ____________
Diagnosis: _________________________________________________ Code: ____________
Diagnosis: _________________________________________________ Code: ____________
Significant psychosocial and contextual features: ______________________________________ ______________________________________________________________________________


Prognosis:



Disposition/Referral:



Comments:



___________________                          ________
Signature                                               Date


Other Components that Might be Included in a Psychosocial Assessment

There are a variety of other elements that might be added to your own template of a psychosocial assessment. Your choice to add any of these elements will be based upon the balance you wish to strike between concision/efficiency and thoroughness. Some of these decisions might be based upon the actual make-up of clients in your practice.

For instance, if your work involves intervention with a number of elderly clients who require assistance from paid and unpaid caregivers, you may choose to include a section in the assessment form that gathers and records information obtained from these important parties. If your caseload includes a number of people for whom religion or spirituality is important in terms of overall understanding of their choices and actions, you may wish to add a section that allows for the gathering and recording of that kind of information. If you work with clients from many different cultures and cultural considerations play into important treatment decisions, you may choose to add an additional section to the assessment form to record information of that sort.

The goal of the template you create for yourself is to remain thorough, while creating efficiency. This is a balance that you must strike for yourself in finalizing your design. The Concise Psychosocial Assessment Template for Children/Adolescents There are a few minor differences between the concise assessment form for adults and for children and adolescents. The most pronounced change in this form is concerned with the addition of the sections covering developmental history and family history. Many clinicians may choose to have these sections also present in their assessment forms for adults, as this information in many cases has important clues to the full diagnostic picture of adult clients. 

However, it is almost always essential for this information to be included in an assessment of a child still residing with his/her parents or guardians. There are also some subtle differences present in the section recording information about psychosocial stressors. Academic and social/peer group stressors have been added to the checklist, encouraging these items to be a routine part of the assessment process. 

You will note in the template presented below that a section for substance abuse assessment has been retained in this form. Children as young as 7 or 8 should routinely be assessed for both the presence of substances in their peer group and assessed for signs and symptoms of eating disorders. These two categories of problems have descended into younger and younger age groups. The section on domestic violence has been de-emphasized in this form. This is not to say that children and adolescents do not engage in domestic violence, including physical and sexual violence towards siblings and other close relatives. However, this information can be noted in other sections.

Below you will find the template for the template sections that are different for the concise assessment of a child or adolescent.


Developmental History (Include milestones and delays, past social, behavioral or academic concerns)
 
Family History (Losses, moves, family history of violence, financial or legal problems, environmental problems)


Prior Individual or Family 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) 

___Academic (Explain): __________________________________________________________
___Social/Peer Group[ (Explain): __________________________________________________________
___Housing (Explain): __________________________________________________________
___Legal (Explain): __________________________________________________________
___Financial (Explain): __________________________________________________________
___Family (Explain): __________________________________________________________
___Other (Explain): __________________________________________________________

 

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