Psychosocial History
Client Name
*
First Name
Last Name
Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
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31
Day
Please select a year
0
01
011
0111
01111
Year
Age
*
Gender Identity
*
Please Select
Woman
Man
Non-binary
Transgender
Prefer not to say
Other
Pronouns
*
Please Select
She/Her
He/Him
They/Them
Other
Current Living Arrangement
*
Alone
With Family
With Partner
Roommates
Other
Who do you live with?
*
Relationship Status
*
Single
Married
Partnered
Divorced
Widowed
Other
Children (names & ages)
Support System (friends, family, community)
Religious/Spiritual Affiliation (optional)
Cultural or Identity Factors Important to Your Care
Occupation
Employer
Currently Working?
*
Yes
No
Student
Highest Education Level
*
Please Select
High School
Some College
College Degree
Graduate Degree
Additional Education Details
What brings you to therapy at this time?
*
What are your goals for therapy?
*
What would you like to be different in your life six months from now?
Have you received mental health treatment before?
*
Yes
No
If yes, please describe previous mental health treatment
Have you ever been hospitalized for mental health concerns?
*
Yes
No
If yes, please explain hospitalization for mental health concerns
Current symptoms (check all that apply)
Anxiety
Depression
Trauma
Panic Attacks
Mood Swings
Sleep Issues
Suicidal Thoughts
Self-Harm
Substance Use
Relationship Issues
Stress
Other
Any history of self-harm or suicide attempts?
*
Yes
No
If yes, please describe history of self-harm or suicide attempts
Primary Care Provider Name & Contact
Current Medical Conditions or Diagnoses
Current Medications (including dosage & purpose)
Allergies (medication, food, etc.)
Substance Use (check all that apply)
Alcohol
Tobacco
Cannabis
Other Substance
Additional Information
Back
Next
PHQ-9 (Depression Screening)
*
Rows
Not at all
Several days
More than half the days
Nearly every day
Little interest or pleasure in doing things.
Feeling down, depressed, or hopeless.
Trouble falling or staying asleep, or sleeping too much.
Feeling tired or having little energy.
Poor appetite or overeating.
Feeling bad about yourself—or that you are a failure.
Trouble concentrating on things, such as reading or watching TV.
Moving or speaking so slowly that others could have noticed? Or being so restless that you are moving around a lot more than usual.
Thoughts that you would be better off dead or of hurting yourself in some way.
GAD-7 (Anxiety Screening)
*
Rows
Not at all
Several days
More than half the days
Nearly every day
Feeling nervous, anxious or on edge.
Not being able to stop or control worrying.
Worrying too much about different things.
Trouble relaxing.
Being so restless that it is hard to sit still.
Becoming easily annoyed or irritable.
Feeling afraid as if something awful might happen.
ACE Questionnaire (Childhood Trauma)
*
Rows
Never
Once
More than once
Prefer not to say
Emotional Abuse: Did a parent or adult in the household often swear at you, insult you, or put you down?
Physical Abuse: Did an adult in the household often push, grab, slap, or throw something at you?
Sexual Abuse: Did an adult or person at least 5 years older than you ever touch you sexually or have you touch them?
Emotional Neglect: Did you often feel that no one in your family loved you or thought you were special?
Physical Neglect: Did you often feel you didn't have enough to eat, had to wear dirty clothes, or had no one to protect you?
Parental Separation: Were your parents ever separated or divorced?
Domestic Violence: Did you see your mother (or stepmother) being pushed, slapped, or hit?
Substance Abuse: Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?
Mental Illness: Was a household member depressed or mentally ill, or did a household member attempt suicide?
Incarceration: Did a household member go to prison?
Should be Empty: