Psychosocial Assessment Name:

ID No:
Direcfions: After Ma assessment /nrer few, check off/fems that apply. Write
infonnation obtained from fñe interview. If subject area is not app/lead/e, wfite N/A. Date of Birth:
Date of Initial Assessment:
Status:
Appearance and General Behavior

O Appropriate attire 0 Oriented to time, place and person Guarded/avoidant

0 Clothing disheveled 0 Disoriented/confused Uncooperative
0 Poor hygiene 0 Pressured speech Agitated
0 Cooperative 0 Psychomotor retardation Other:

Comment:
Mood/Affect
0 Normal mood Labile Depressed/sad
0 Appropriate to content Irritable Anxious
0 Adaptable Inappropriate to content Other:
O Flat affect Euphoria/elated
0 Angry/hostile Anhedonia

Comment:
General Functioning/Behavior
D Able to abstract Potential for suicidal ideation Impaired concentration memory
0 Logical/goal directed Limited insight social withdrawal/isolation
0 Alert Poor anger management Articulates needs and issues
0 Fully oriented Low self-esteem Impaired judgment
0 Poor impulse control Decreased attention span Other:

Comment:
Coping Mechanisms/Resources
0 Able to live independently 0 Adequate problem-solving skills Able to ask for assistance
0 Insight oriented 0 Able to articulate needs/concerns Adequate coping/stress management skills
0 Good judgment 0 Able to reach out to others Takes responsibility for actions
0 Able to make decisions 0 Appropriate emotional expression Other:

Comment:
Living Status
0 Independent Lives with friends HUD housing
O Lives with family Group/institutional Other:
Lives with partner Homeless/shelter

Comment:
Support Network/Resources
0 Family Substance abuse treatment 12 step programs:
0 Friends/co-worker None Mental health agency:
0 Significant other Community support group/agencies Religious/social affiliation

Comment:

Perception of Support System as Reported by Participant:

Receiving Services from Other Agencies/Service Providers: O Yes 0 No

Agencies:

Significant Cultural/Religious Issues: O Ye s O No

 Name:

Involvement with Legal System: O Current O Past O No

Status of Current Legal Involvement:

Cigarettes/Smokeless Tobacco (Pre-contemplation) (Contemplation/Preparation) (Action)

Current usage: 0 Yes O No O Does not want to quit 0 Wants to quit 0 Ready to quit
Other household members: 0 Yes O No O Does not want to quit 0 Wants to quit 0 Ready to quit
Client has (increased) (decreased) tobacco use: (cigarettes) (smokeless tobacco) (other:
Education provided: 0 Tobacco use 0 Second hand smoke risk
# of successful (> one week) quit attempts in lifetime: Has tobacco related illness:
If pregnant, stopped usage upon learning of pregnancy: 0 Yes O No During pregnancy, started usage again: 0 Yes

History of Dependency/Addiction: 0 Yes O No Family History of Dependency/Addiction: 0 Yes O No

Current Use of Alcohol: Type: Frequency: Amount:
Readiness for Change: 0 Pre-contemplation 0 Contemplation/Preparation 0 Action 0
Alcohol treatment 0 Yes O No Provider: Last date treated:
If pregnant, stopped usage upon learning of pregnancy: 0 Yes O No
Other Drugs
History of Addiction O Yes No Family History of Abuse/Addiction: 0 Yes O No
Current Use Type: Frequency: Amount:
O Marijuana 0 Cocaine/Crack 0 Hallucinogens O Opiates O Benzodiazepines
0 Amphetamine O Barbiturates O Inhalants O Prescription med.:
Readiness for Change: 0 Pre-contemplation 0 Contemplation/Preparation 0 Action 0 N/A
Drug Treatment O Yes O No Provider: Last Date Treated:
If pregnant, stopped usage upon learning of pregnancy: 0 Yes O No

Mental Health History

Current Past Current Past
Mental health history 0 0 Marital discord 0 0
Depressed mood 0 0 Suicidal plan/attempt 0 0
Social impairment, including family relationship 0 0 Family dysfunction 0 0
Impairment in occupational functioning/ADLS 0 0 Impairment of judgment O 0
Impairment in school functioning 0 0 Anxious Mood O 0
Other: 0 0 Poor conduct/impulse control 0
Other: 0 0 Familial history: 0 Yes O No

Mental Health/Substance Abuse History: Treatment/Dates/Follow-up/Response: