PSA6669 - SECTION 12: CONCISE PSYCHOSOCIAL ASSESSMENT TEMPLATES
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