Psychosocial Assessment
Triage Family History
Where was client born and raised?
How does client describe his/her childhood? (Good/Fair/Poor/N/A)
Comments:
Were client’s parents ever divorced or separated? (yes/no) If yes, how old was client?
Who was client’s primary caregiver?
Was there ever a time when client’s primary caregiver(s) was
someone other than biological parents? (yes/no) If yes, who?
How does client describe his/her relationship with:
Mother (Good/Fair/Poor/N/A) Father (Good/Fair/Poor/N/A)
Comments:
How many brothers and sisters does client have?
Brother(s) Sisters(s)
Where is client in the birth order?
How does client describe his/her relationship with siblings growing up? (Good/Fair/Poor/N/A)
Comments:
How does client describe his/her current sibling’s relationship? (Good/Fair/Poor/N/A)
Comments:
Are client’s parents still living? (yes/no)
If no, describe circumstances and impact (including client’s age at the time of the death).
If client’s parents are still living, how does client
describe his/her current relationship with them? (yes/no) Comments:
Is there any known family history of mental illness or substance abuse? (yes/no)
If yes, describe impact on client:
Were there any cultural and/or social issues that impacted client in childhood? (yes/no)
If yes, describe:
Describe financial situation of family during childhood:
Relationships
Client’s sexual orientation (Heterosexual/Homosexual/Bisexual/NA)
Does client have any concerns about his/her sexual practices? (yes/no)
Has anyone else expressed concern about client’s sexual practices? (yes/no)
Has client’s sexual behavior ever lead to involvement with the law? (yes/no)
Comments/additional information:
Has client ever been married? Is yes, how many times?
Duration of marriages(s) Current marital status:
If married, how does client describe his/her relationship with spouse? (Good/Fair/Poor/N/A)
Comments:
If not married, is client currently in a relationship? If yes, how long?
How does the client describe his/her current relationship? (Good/Fair/Poor/N/A)
Comments:
Describe any other significant relationships:
In previous relationships, name precipitating factors leading to dissolution of these relationships:
Does client have any children? If yes, list age and sex:
How does client describe his/her relationship with the children? (Good/Fair/Poor/N/A)
Comments:
Describe child custody or divorce issues, if any:
Abuse History
Does client have a history of being
abused:
As an adult? (yes/no) As a child? (yes/no)
Verbal Physical Emotional Sexual Neglect Exploitation
Explain:
Is client currently being abused?
Verbal Physical Emotional Sexual Neglect Exploitation
Explain:
Spiritual & Cultural Issues
Was client raised in any particular religious faith? If yes, which one?
Is client a member of a religious faith? If yes, which one?
Does client believe in a higher power?
Are client’s spiritual beliefs a support to him/her? (yes/no)
Are there any specific cultural, ethnic, or religious beliefs/practices client would like to have
considered in treatment? (yes/no)
If yes, explain:
Educational Status & History
Current/Highest grade completed: Current/Last school attended:
In general, what grades did client (does client) make in school?
Special school placements/achievements:
Describe client’s relationship with teachers and peers:
Does client have plans for future education? (yes/no)
If yes, describe:
Does client have difficulty with reading or writing? If yes, explain:
Client’s primary language is:
Financial at Entry
List all income sources and amounts:
Employment Status & History
Employment Status: (Full-time, Part time, volunteer unemployed)
Current Occupation Length of current employment
Hours: Number of days worked for pay in past month:
Is client or client’s family experiencing any financial problems? (yes/no)
If yes, describe:
Does client have any difficulties at his/her job? (yes/no) If yes, describe:
Is client satisfied with his/her job? Comments:
What is client’s employment history?
Is the client a Veteran? (What type of veteran)
If yes, describe duties/type of service:
If dishonorable, why?
Living Arrangements
Does the client live alone? If no, who does the client live with?
What does the client like about his/her living arrangements?
What does the client dislike about his/her living arrangement?
How long has the client been living there?
Housing Type:
Rent Own Temporary Permanent Other:
Activities Information
Activities client likes to do in his/her free time:
Hobbies or skills:
Personal strengths or positive qualities:
Personal weaknesses or negative qualities are:
Client spends free time with:
Family: Friends: Co-Workers: Alone: Other:
In leisure activities client reports:
Decrease: Increase: No Change:
Legal Status & History
Does client have any current legal problems? If yes, describe:
Has client had any previous legal problems? If yes, describe:
Contacts:
Was client ever court ordered to participate in treatment? If yes, describe:
Was client ever involved in a violent crime? Comments/Concerns:
