ADULT PSYCHOSOCIAL

ADULT PSYCHOSOCIAL
Name:
DOB:

MonthDayYear
Date
DATE:

MonthDayYear
Date
Preferred Pronouns:
Cell Phone:
Email*
example@example.com
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What brings you to our Clinic?
Are there family members or friends who you think will be supportive of your treatment?
What would you like to accomplish here?
MENTAL HEALTH ASSESSMENT:
Describe those thoughts, feelings, behaviors or situations causing difficulty for you:
Describe those thoughts, feelings, behaviors or situations causing difficulty for you:
Do you have any concerns or problems in any of the following areas? Please check all that apply.

Appetite/eatingSleepingSexual activitySexualityEnergy levelPhysical or sexual abuse
Temper tantrums/angerNervousness/excessive worryMemory or recall difficultiesRepetitive behaviorsPersistent feeling of sadness/hopelessnessThoughts of harming someone else, harming yourself, or being harmed by someone else.
Do you have any concerns or problems in any of the following areas? Please check all that apply.

Appetite/eatingSleepingSexual activitySexualityEnergy levelPhysical or sexual abuse
Temper tantrums/angerNervousness/excessive worryMemory or recall difficultiesRepetitive behaviorsPersistent feeling of sadness/hopelessnessThoughts of harming someone else, harming yourself, or being harmed by someone else.
Appetite/eating
Sleeping
Sexual activity
Sexuality
Energy level
Physical or sexual abuse
Temper tantrums/Anger
Nervousness/excessive worry
Memory or recall difficulties
Repetitive behaviors
Persistent feelings of sadness/hopelessness
Thoughts of harming someone else, harming yourself, or being harmed by someone else
Other (please explain)
Other (please explain)
Do you have any special concerns or problems getting along with your children, parents, coworkers, spouse, or significant other?
What do you consider your strengths?
What do you consider your strengths?
What do you consider your weaknesses?
What do you consider your weaknesses?
Have you had any mental health treatment in the past? (Where, when and if successful)
Have you had any mental health treatment in the past? (Where, when and if successful)
Briefly describe your biological parents, your relationship to them, and whether they are living:
Briefly describe your biological parents, your relationship to them, and whether they are living:
Who raised you as a child? (biological mother, biological father, other?)
List all siblings by name, age, sex:
List all siblings by name, age, sex:
Briefly describe the kind of living situation you grew up in:
Briefly describe the kind of living situation you grew up in:
What is your cultural/ethnic background?
Spiritual/religious orientation in your family of origin:
Have there been any of the following kinds of problems with any of your blood relatives?
Severe temper tantrums or mood problems
Mental Illness:
Problems with alcohol or other drug abuse:
Physical or sexual abuse:
Criminal behavior:
Homicidal or suicidal behavior:
Any serious problems or unusual circumstances with your birth?
Any special problems or challenges you faced growing up as a child?
As a child growing up, did you experience anything you would consider traumatic?
The best part of your youth was
The worst part of your youth was
How did you do in school?
Highest grade completed:
Any time in the military?
Are you currently employed?
Marital status:
List all children: (Names, ages, whether living with you)
How do you Identify in your sexual orientation?
What is your current living situation?
What are your current spiritual/religious practices?
Do you have any money problems?
Do you have any legal problems?
Do you have an arrest history?
What do you do for recreation or as a hobby?
HEALTH/MEDICAL:
Check all that are problem areas:

Abdominal PainDizzinessHeadachesSleep ProblemsBed WettingEar infectionHearing problemsWeight lossBreathing problemsTics or twitchingEye/vision problemsWeight gainChest painFainting spellsNauseaChronic pain
Chronic painFatigueNose bleedsHot flashesConstipation/diarrheaFrequent urinationOther bleedingHeat/cold sensitivityCoughsAllergiesMenstrual painSweatingSore throatProstrateOther
Check all that are problem areas:

Abdominal PainDizzinessHeadachesSleep ProblemsBed WettingEar infectionHearing problemsWeight lossBreathing problemsTics or twitchingEye/vision problemsWeight gainChest painFainting spellsNauseaVomiting
Chronic painFatigueNose bleedsHot flashesConstipation/diarrheaFrequent urinationOther bleedingHeat/cold sensitivityCoughsAllergiesMenstrual painSweatingSore throatProstrateOther
Abdominal pain
Dizziness
Headaches
Sleep problems
Bed wetting
Ear infection
Hearing problems
Weight loss
Breathing problems
Tics or twitching
Eye/vision problems
Weight gain
Chest pain
Fainting spells
Nausea
Vomiting
Chronic pain
Fatigue
Nose bleeds
Hot flashes
Constipation/diarrhea
Frequent urination
Other bleeding
Heat/cold sensitivity
Coughs
Allergies
Menstrual pain
Sweating
Sore throat
Prostrate
Other
Check all that have occurred at any time:

AIDS/HIVDental problemsRheumatic feverAnemiaGlaucomaSeizureArthritisHeart diseaseAsthmaHigh blood pressureThyroid problems
Kidney diseaseCancer/tumorDiabetesVenereal diseaseBlood transfusionLoss of consciousnessBlows to the head/head injuryStrokeAbuse: physical/sexual/verbalPregnancyOther
Check all that have occurred at any time:

AIDS/HIVDental problemsRheumatic feverAnemiaGlaucomaSeizureArthritisHeart diseaseAsthmaHigh blood pressureThyroid problems
Kidney diseaseCancer/tumorDiabetesVenereal diseaseBlood transfusionLoss of consciousnessBlows to the head/head injuryStrokeAbuse: physical/sexual/verbalPregnancyOther
AIDS/HIV
Dental problems
Rheumatic fever
Anemia
Glaucoma
Seizure
Arthritis
Heart disease
Asthma
High blood pressure
Thyroid problems
Kidney disease
Cancer/tumor
Diabetes
Venereal disease
Blood transfusion
Loss of consciousness
Blows to the head/head injury
Stroke
Abuse: physical/sexual/verbal
Pregnancy
Other
List any operations or hospitalizations for medical problems:
List any operations or hospitalizations for medical problems:
Are you currently taking any prescribed medication? (Add additional sheet if necessary)

Drug Dose Times daily Physician Condition
Over-the-counter medications taken regularly (include herbal preparations):

Drug Frequency Amount Condition
Are you allergic to any medications?
Have you had trouble accessing appropriate medical care?
Are you currently under the care of a physician for any active medical problems at this time?
Name of primary care physician:
Office location:
Date of last physical examination:

MonthDayYear
Date
Have any of your blood relatives have what you would call a significant drinking or drug use problem - one that did or should have
Do you now, or have you ever, had a problem with alcohol or drugs?
Has anyone else ever said you have/had a problem with alcohol or drugs?
Have you ever been in treatment for substance use?
Have you ever attended support groups for substance use?
SUMMARY:
Is there anything else we should know about you?
Is there anything else we should know about you?
Signature

Clear
Interviewing clinician/date

MonthDayYear
Date
Should be Empty:

ADULT PSYCHOSOCIAL

MENTAL HEALTH ASSESSMENT:

HEALTH/MEDICAL:

Are you currently taking any prescribed medication? (Add additional sheet if necessary)

Over-the-counter medications taken regularly (include herbal preparations):

SUMMARY: