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Psychosocial Assessment Intake Interview

DEMOGRAPHIC INFORMATION
Name: ________________________ Date: _____________________
Address: ______________________ Date of Birth: ______________
________________________ Age: _____________________

Phone Number: _________________ Insurance information: _________________

Referred by: ____________________
x Releases signed
x Consent to Treatment signed
Diagnosis: ___________________________
____________________________________
____________________________________
x Insured
x Uninsured
PCP: Dr. ______________________
Psychiatrist:____________________
Dominate Hand: R / L
Marital status: __________________

PRESENTING PROBLEM
Chief complaint: __________________________________________________________
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________________________________________________________________________
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Mood (self-reported): _____________________________________________________
Affect (observed by clinician): ______________________________________________
Current symptoms:
‰ Anxious ‰ Memory loss
‰ Appetite changes ‰ Motivation difficulty
‰ Concentration difficulty ‰ Pain
‰ Indecisiveness ‰ Panic attacks
‰ Racing Thoughts ‰ Restlessness/psychomotor
‰ Delusions agitations or psychomotor
‰ Depressed mood retardation
‰ Difficulty sleeping F/A/R ‰ Suicidal thoughts
‰ Hx of Eating disorder ‰ Weight loss or gain
‰ Fatigue #_____ time frame_______
‰ Fears
‰ Feelings of guilt/ worthlessness
‰ Hopefullness/Hopeless
‰ Flashbacks/Dreams
‰ Hallucinations
‰ Social Withdrawal
‰ Homicidal thoughts
‰ Impulsivity
‰ Compulsivity
‰ Irritability/Anger outbursts
‰ Loss of interest or pleasure
‰ Manic symptoms
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Life Stressor Notes: _______________________________________________________

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Patient’s Long Term Goals: _________________________________________________

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Patient’s Short Term Goals: _________________________________________________
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Patient’s Strengths (3): _____________________________________________________

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Support System: __________________________________________________________

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MENTAL HEALTH HISTORY

Previous mental health treatment (Psychiatrist, Psychologist, counselor, inpatient

hospitalization):___________________________________________________________
________________________________________________________________________
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MEDICAL HISTORY:

Developmental history (pregnancy, delivery, developmental milestones):_____________

________________________________________________________________________
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Current medical conditions: _________________________________________________

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Past medical issues (childhood diseases, remissions, surgeries, etc): _________________

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Allergies: _______________________________________________________________
History of family illnesses: _________________________________________________
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Current medications (including OTC and herbal remedies) :________________________
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SOCIAL HISTORY:

Relationships with parents: _______________________________________________________

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Relationships with siblings: _______________________________________________________

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Abuse history: _________________________________________________________________

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School performance: ____________________________________________________________

Highest level of education: _______________________________________________________

Regular classes or special needs: ___________________________________________________

Marital/Significant relationship history:______________________________________________

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______________________________________________________________________________

Current status and family relationships (number of years married, spouse, children, etc.):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Sexually Active (age of onset): ____________________________________________________

x monogamous
x multiple partners
x same sex (include experimentation)
x Disease Protection use : ____________________________________________________
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x Birth Control use: _________________________________________________________

x Dysfunction
x Rate Level of Satisfaction (physical enjoyment, emotional satisfaction, &frequency) : ___
___________________________________________________________________________

EMPLOYMENT HISTORY:

Current employment: ____________________________________________________________

______________________________________________________________________________
______________________________________________________________________________

Work history: __________________________________________________________________

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LEGAL HISTORY:

Current legal involvement: _______________________________________________________

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Past legal involvement: __________________________________________________________

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MILITARY HISTORY:

Past or current military involvement:________________________________________________

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SUBSTANCE USE/ABUSE HISTORY:

Alcohol use history (age of onset, amount, frequency, duration, problematic, etc.):____________
______________________________________________________________________________
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Family History of Alcohol use (age of onset, amount, frequency, duration, problematic, etc.):___
______________________________________________________________________________
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Substance use history (age of onset, amount, frequency, duration, problematic, etc.) __________
______________________________________________________________________________
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______________________________________________________________________________
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Family History of Substance use (age of onset, amount, frequency, duration, problematic, etc.) _
______________________________________________________________________________
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Nicotine use: __________________________________________________________________

Caffeine use: __________________________________________________________________

Problematic Behaviors (age of onset, amount, frequency, duration, problematic, etc.):_________

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Other: ________________________________________________________________________
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Physical Appearance: Hair_____________________Height______________________

Weight___________________Body Type___________________
Other________________________________________________
Motor Activity: Walking__________________Standing_____________________
Sitting___________________Range of Motion_______________
Other________________________________________________