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What is a psychosocial assessment?

An examination of an individual’s mental health, as well as their social well-being, is referred to as a psychosocial assessment. It examines the individual’s self-perception and capacity to operate normally in society. The purpose of the psychosocial evaluation is to understand the patient so that one may give the very best treatment and assist the person in reaching their full potential in terms of health.

The psychosocial evaluation provides the nurse with information that assists her in determining whether the patient is in a state of mental health or mental disease. A person is said to be in a state of mental health when they can cope with the everyday pressures of life, function well in their jobs, and make positive contributions to their communities.

Mental illness may be defined as a pattern of actions that upset the person experiencing it or the community in which they reside. Mental illness can distort reality, impact day-to-day functioning, or impair judgment. People with mental illness often exhibit maladaptive behaviors, diminished capacity to operate, and diminished ability to interact with society.

Psychosocial nursing assessment and intervention

Identifying the patient is the first thing that must be done in any Psychosocial assessment nursing. The name of a patient, their gender, birth date or age, marital status, race, ethnicity, and the languages that they speak are all components of a patient’s identification.

In the patient’s own words, the principal complaint is the primary reason they seek medical attention. The chronological description of the events that lead up to the primary complaint is what is meant by the term “the history of the current disease.” In this area, you could add information on the problem’s location, duration, severity, timing, context, modifying circumstances, and accompanying signs or symptoms.

The psychiatric and psychological history provides a comprehensive account of all psychiatric and psychological issues that have been addressed in the past. The medical or surgical history comprises a list of all medical conditions, a record of all operations, and the dates of those procedures. It is essential to record the drugs currently being taken and those taken in the past in the Psychosocial assessment form. A record should be kept of the physician who prescribed any prescribed prescriptions and the reason(s) for the prescription. When it comes to drugs that have been given in the past, it is essential to keep a record of the reasons why they were first taken and the reasons why they were discontinued

The past use of alcoholic beverages and drug usage is an essential component of the psychological evaluation. Documentation of the drugs presently being used should include details such as the route of administration (orally, intravenously, intramuscularly, or intranasally), the dosage, the frequency, and the duration of usage. Documentation is required for any drugs that have been used in the past. Drugs such as alcohol, heroin, opiates, marijuana, cocaine, crack, methamphetamines, inhalants, stimulants, hallucinogens, caffeine, and nicotine are commonly abused.

Evaluation of abuse, homicidal risk, and suicidal thoughts are a Psychosocial assessment nursing example of the violence risk profile. Attempting suicide in the past, having a history of depression or bipolar disorder, feeling isolated, physical illness, history of aggressiveness or impulsivity, unwillingness to seek help, or barriers to mental health treatment are all risk factors for suicide. It is difficult to predict who will commit suicide. Still, those who have attempted suicide in the past have a history of depression or bipolar disorder, feel hopeless, abuse drugs or alcohol, have a history of suicidal thoughts, or have a history of suicide.

Male gender, connection with gangs, unemployment, use of drugs or alcohol, active psychotic symptoms, and lower socioeconomic position are all risk factors for homicidal conduct. Other risk factors include active psychotic symptoms.

Psychosocial assessment tools

When evaluating a person’s mental health and overall welfare, practitioners in the mental health field employ many tools. Screening for the presence or absence of common mental health conditions, making a formal diagnosis of a mental health condition, assessing changes in symptom severity, and monitoring client outcomes throughout therapy are all common uses for psychological testing.

1. Screening

“Screening” persons for a variety of mental health issues may be accomplished via the use of a few concise psychological tests. Frequently, patients are asked to fill out questions as part of the screening process. If a positive result is detected on a screening test, then the screening test may be followed up with a more conclusive test. Screening tends to be rapid to conduct, but the findings are just suggestive.

2. Diagnosis

Establishing a definitive diagnosis of a mental health condition might be aided by using psychological evaluation procedures by a skilled physician. When evaluating a person’s mental health to support a diagnosis, it is possible to use validated questionnaires and semi-structured diagnostic interviews. Items included in self-report measures used for diagnosis are often closely connected to criteria listed in diagnostic manuals (ICD and DSM).

3. Monitoring of symptoms and the results

One branch of evidence-based practice requires therapists to use outcome measures to monitor progress and immediate treatment path. It is common practice for psychologists, CBT therapists, and other mental health providers to request that their patients complete self-report assessments to monitor any shifts in the intensity of their symptoms.

Psychosocial Status Examination

This assessment entails a mental status examination. The function of the brain, as well as mental functions and behaviors, are evaluated as part of the mental status evaluation. An accurate assessment of a patient’s mental status may help diagnose various conditions related to mental health or the central nervous system. A thorough evaluation of a patient’s mental state may be utilized during the treatment to track how seriously they are unwell.

The level of the patient’s arousal is the first thing that is evaluated while assessing their mental state. Is the patient awake, dozing off, attentive, or unresponsive to your questions? Is the patient aware of who they are, where they are, and what time it is, or does the patient seem confused?

How does the patient seem currently? Is the patient in good personal hygiene? Is eye contact appropriate? Note the lack of regard for looks, bad hygiene, and improper clothing. An indication of a potential mental health issue is poor personal hygiene. A stooped posture and an inability to maintain eye contact are also signs of despair. A manic mood is sometimes indicated by eccentric or brightly colored clothing.

Conduct a behavior and motor activity assessment. Is the patient serene and unruffled, or do I detect any signs of fidgetiness, agitation, or drowsiness in their behavior? Take note of any motor changes that are not normal, such as facial expressions that are not typical, tremors, or tics. Tics and tremors are symptoms that may point to a neurological condition, an adverse reaction to medicine, or anxiety. Excessive bodily movements may indicate mania, anxiety, or the use of stimulants. Obsessive-compulsive disorder may be present when there is a pattern of repeated motor actions. Depression, catatonic schizophrenia, or substance misuse are potential causes of little bodily movement.

Consider the disposition and the impact. A straightforward method for determining a patient’s disposition is to inquire about their state of emotional well-being through a psychosocial assessment questionnaire. Does this questionnaire ask psychosocial assessment questions, such as Is the patient’s emotional reaction to the circumstance reasonable given the circumstances? Again, one should determine someone’s mood by paying attention to verbal and non-verbal cues. Mood disorders are characterized by improper thoughts, emotions, or behaviors in response to the context of the scenario. Unusual symptoms include euphoria, agitation, a gloomy mood, a flat affect, anxiety, labiality (the quick transitioning from one affect to another), anger, excessive fury, apathy, carelessness, and an inability to feel emotions, and a lack of compassion.

A significant portion of the psychosocial evaluation focuses on the speaker’s manner of speech. The patient’s voice should be strong, clear, fluent, and eloquent, and they should be able to convey their thoughts. Take note of any irregularities in the speech that are listed below.

Slurred or jumbled speech
Conversational tone
Loud speech
Communication under duress
Interaction that is just minimal
Incoherent discourse
Halting speech
Rapid speaking
People who suffer from depression often have poor communication skills.
Take into account the patient’s frame of mind. Is the patient willing to participate?
Uncooperative, suspicious, aggressive, or all of the above?

Individuals can self-express their thinking processes, and others may witness these processes via their speech. It is not the material that is communicated so much as the patterns of verbalization that are important. It might be any of the terms listed in Table 2, ranging from average to extreme. A typical cognitive process is rational, pertinent, sequential, and consistent.

Psychosocial assessment template

Below is a sample of a psychosocial assessment example paper, otherwise known as a template. The template is filled by the client hence the name of a fillable psychosocial assessment form.

CHILD/ADOLESCENT PSYCHOSOCIAL ASSESSMENT

Date of appointment: ________________________ Time of appointment: ___________________________

Client Name: _______________________________ Age: _________ DOB: __________________________

Gender: £ Male £ Female £ Transgender Preferred Name/Nickname: ___________________________

Ethnicity: £ Hispanic £ Non‐Hispanic Race: ___________________________

Name of Person completing form: __________________________ Relationship to client: _________________

PRESENTING PROBLEM: (Briefly describe the issues/problems which led to your decision to seek therapy services).

___________________________________________________________________________________________

How severe do you rate your child’s presenting problems on a scale of 1‐10 (with one being the most severe)?

MOST SEVERE 1 2 3 4 5 6 7 8 9 10 LEASTSEVERE

PRESENTING PROBLEM CATEGORIZATION:(Pleasecheckalltheapplyandcirclethedescriptionofsymptom)

Symptoms causing concern, distress or impairment:

Change in sleep patterns (please circle): sleeping more sleeping less difficultyfallingasleep

difficulty staying asleep difficulty waking up difficultystayingawake

Concentration: Decreased concentration Increasedorexcessiveconcentration
Change in appetite: Increased appetite Decreasedappetite
Increased Anxiety(describe):__________________________________________________________
Mood Swings (describe): ______________________________________________________________ £ Behavioral Problems/Changes (describe):

_____________________________________________________________________________________ _____________________________________________________________________________________

Victimization (please circle): Physical abuse, Sexual abuse, PsychologicalAbuse

Robbery victim Assault victim Dating violence DomesticViolence

Human trafficking DUI/DWI crash Survivorsofhomicidevictims

Other:______________________________________

Other (Pleasedescribeotherconcerns):____________________________________________________

_____________________________________________________________________________________

How long has this problem been causing your child distress?(pleasecircle)

One week One month 1 – 6 Months 6 Months – 1 Year Longerthanoneyear

How do you rate your child’s current level of coping on a scale of 1 – 10 (with one being unable to cope)?

UNABLE TO COPE 1 2 3 4 5 6 7 8 9 10 ABLETOCOPE

FAMILY COMPOSITION:

Mother’s Name: _________________________________________________ Age:___________

Living with child £ Not living with child Employed Currently? £ Yes £No

PlaceofEmployment:_____________________________Occupation:___________________________

Father’s Name: _________________________________________________ Age:___________

Living with child £ Not living with child Employed Currently? £ Yes £No

PlaceofEmployment:_____________________________Occupation:___________________________

Marital status of Parents: £ Single £ Married £ Divorced £ Widowed £DomesticPartnership

Please list the names, ages, relationships, and other relevant information regarding all immediate family members living in or outside the home. Please include all members currently residing in the child’s household.

Name	Gender	Age	Relationship To Client	Living With Child
				£ Yes £ No
				£ Yes £ No
				£ Yes £ No
				£ Yes £ No
				£ Yes £ No
				£ Yes £ No
				£ Yes £ No

What else do you feel/believe would be helpful, or important for us to know/understand about your relationships with your family or about your family members?

___________________________________________________________________________________________ ___________________________________________________________________________________________ RECENT LOSSES:

Family Member £ Friend £ Health £ Lifestyle £ Job £ Income £ Housing £None

Who?_______________________________When?_________________NatureofLoss?__________________

OtherLosses:________________________________________________________________________________

Additionalinformation(ifneeded):

Were there any complications during pregnancy? £ Yes £ No Ifyes,pleaseexplain:__________________

___________________________________________________________________________________________

Full‐term Birth £PrematureBirth

Were there any complications during birth? £ Yes £ No Ifyes,pleaseexplain:___________________

___________________________________________________________________________________________

Were drugs or alcohol consumed during pregnancy? £ Yes £No

Child’s weight at birth? ______ lbs. ______ oz. Child’s health at birth? ________________________________

Length of hospital stay? ______________________________________ Post‐partum depression? £ Yes £No

Was your child adopted? £ Yes £ No Ifyes,atwhatage?____________

Domestic adoption £ International adoption (Country:_______________________)

DEVELOPMENTAL HISTORY:

As accurately as you can remember, how old was your child when she/he:

Rolled over? ______ Crawled? _______ Walked? ______ Talked (two words)? ______ Toilet Trained? _______

Do/did you have concerns about your child’s development in any of these areas (below)?

Speech/Language £ Motor Skills £ Cognitive/Intellectual £ Sensory £ Behavioral £ Emotional £Social

Ifso,pleasedescribe:__________________________________________________________________________

___________________________________________________________________________________________ Were there any significant disturbances/changes during your child’s childhood? £ Yes £No

Ifyes,pleasedescribe:_________________________________________________________________________

How would you describe your child’s overall health?________________________________________________

Does your child have any health issues? £ Yes £ No Ifyes,pleaselistbelow:________________________

___________________________________________________________________________________________

Does your child have recurrent medical conditions such as ear infections, asthma, or allergies? £ Yes £ No

Ifyes,pleaseexplain:________________________________________________________________________

Does your child have tubes in their ears? £ Yes £ No

Include current significant medical problems, physical limitations, sleep problems, unusual eating habits, poor hygiene, overall physical fitness, head injuries, early childhood infections, eating disorders, knee or back injuries, asthma, etc.)

Medical Conditions	Currently, receiving treatment?	Provider	Does this condition cause stress or impairment at this time?	What have you found that helps?

Does your child take any medications? £ Yes £ No

Please list medications (including psychotropic, over‐the‐counter, and herbal remedies) that you have taken in the past six months

Medication	Dosage	Frequency	Prescribed By	Reason for Medication

Is your child taking the medications as prescribed? £ Yes £ No IfNo,pleaseexplain:________________

___________________________________________________________________________________________

Additionalinformation(ifneeded):______________________________________________________________

___________________________________________________________________________________________

Has your child ever had a serious accident/illness or hospitalization? £ Yes £No

Please list all past hospitalizations, surgeries, accidents, or illnesses in the chart below.

Reason for Previous Hospitalizations, Accident, Illness

Date/Location of Hospitalization

Hasyourchildhadthefollowingscreenings(pleasecheckallthatapply)?

Hearing Screening Date:_____________________Outcome:_____________________________________
Vision Screening Date:_____________________Outcome:_____________________________________
Speech/LanguageScreeningDate:__________________Outcome:_________________________________

Primary Care Doctor: _________________________ Facility: ___________________ Phone Number: __________________

PSYCHIATRIC/PSYCHOLOGICAL HISTORY:

Is your child currently being seen by a counselor? £ Yes £No

If yes, name of current counselor ___________________________ Length of Treatment _____________

Is your child currently being seen by a psychiatrist? £ Yes £No

Ifyes,nameofcurrentpsychiatrist__________________________LengthofTreatment_____________

Has your child ever been diagnosed with a mental health, emotional or psychological condition?

Yes £No

If yes, what diagnosis was your child given? ________________________________________________

When? _______________________________________________________________________________

By Whom? ___________________________________________________________________________

Has your child received counseling services or been hospitalized for mental health or drug and alcohol concerns in the past? £ Yes £No

If yes, please list previous counseling/hospitalizations for mental health/drug and alcohol concerns below

Dates of Service	Place/Provider	Reason for treatment	Were the services helpful

Additional information:_______________________________________________________________________

___________________________________________________________________________________________ SAFETY CONCERNS:

Is your child presently suicidal? £ Yes £NoIfYes,pleaseexplain___________________________________

Has your child ever attempted to commit suicide? £ Yes £ No Ifyes,whenandhow?________________

___________________________________________________________________________________________ Is there a history of suicide in your child’s immediate and/or extended family? £ Yes £ No

If Yes, please explain __________________________________________________________________________

___________________________________________________________________________________________

Has your child ever inflicted burns or wound on his/herself? £ Yes £ No

Is your child presently homicidal? £ Yes £ No Ifyes,pleaseexplain_______________________________

___________________________________________________________________________________________AdditionalInformation:(pleaselistadditionalinformationasneededtoaddresspastandcurrentsafetyissues)

___________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________

CURRENT FUNCTIONING:

Do you have concerns about your child in the following areas? (check all that apply)?

£ Eating £ Hygiene/grooming £ Sleeping £ Activities/play £SocialRelationships

Ifso,pleasedescribe:__________________________________________________________________________

___________________________________________________________________________________________

Please rate your child’s personality/temperament (how they behave the majority of the time in each of the following areas on a scale from 1 to 7 by placing a check above the number that best describes your child):

ENERGY/ACTIVITY LEVEL (how active is my child?)

CAN sit still and listen CAN’T sitstillandlisten

for long periods of time ____: ____: ____: ____: ____: ____: ____ for long periods of time 1 2 3 4 5 6 7

NEED FOR PHYSICAL ROUTINE (how much routine does my child need)?

ENJOYS DOING THINGS ENJOYS ROUTINE; easily DIFFERENTLY; may not upset when day doesn’t ____: ____: ____: ____: ____: ____: ____ notice small changes in go as usual 1 2 3 4 5 6 7theday

MOOD (what is my child’s mood most of the time)?

ANXIOUS‐usually CALM‐usuallyrelaxed

frustrated and worried ____: ____: ____: ____: ____: ____: ____ 1 2 3 4 5 6 7

HAPPY‐usually enjoys SAD‐usuallyunhappy;

what he/she is doing ____: ____: ____: ____: ____: ____: ____ hard time having fun 1 2 3 4 5 6 7

CURIOUS‐usually eager TIMID‐usually not

to know something ____: ____: ____: ____: ____: ____: ____ interested 1 2 3 4 5 6 7

ANGRY‐easily frustrated CALM‐usually and annoyed with others ____: ____: ____: ____: ____: ____: ____ composedand

1 2 3 4 5 6 7 peacefulwithothers

INTENSITY (how strongly does my child express feelings, wants, and opinions?)

MILD REACTION‐calm STRONG REACTION‐

and cooperative; Easily ____: ____: ____: ____: ____: ____: ____ may cry or yell over pushed around by others 1 2 3 4 5 6 7 smallthings

PERSISTENCE (Can my child stick with and complete tasks?)

Will stick with something Gives up on tasks; until it is done ____: ____: ____: ____: ____: ____: ____ hastroublefinishing

1 2 3 4 5 6 7 things

SENSITIVITY TO SENSES (How sensitive is my child to light, smells, sounds, and touching?)

Learns by seeing Has strong reaction to

touching and using all ____: ____: ____: ____: ____: ____: ____ noise, lights, hugging his/her senses 1 2 3 4 5 6 7 ortouching

PERCEPTIVENESS (How aware is my child of feelings and emotions?)

Sympathetic to others; Unaware of the

can use words to tell ____: ____: ____: ____: ____: ____: ____ feelings of others how he/she feels 1 2 3 4 5 6 7

ADAPTABILITY (How easily does my child accept changes?)

Often fearful of new	Will easily meet and
people and new ____: ____: ____: ____: ____: ____: ____	accept new people and
situations 1 2 3 4 5 6 7 ATTENTION SPAN/DISCTRACTIBILITY (How well does my child pay attention?)	activities
Stays focused on tasks	Easily sidetracked;
until completed ____: ____: ____: ____: ____: ____: ____	difficulty following
1 2 3 4 5 6 7	directions

PARENT/CHILD RELATIONSHIP

Describe parenting your child (e.g. challenging, easy): _______________________________________________

What do you find most challenging in parenting your child? __________________________________________

What kind of discipline works best with your child? _________________________________________________ EDUCATION

Is your child currently enrolled in school? £ Yes £ No Name of School ______________________________

What grade is your child currently in (if summer, was grade is your child going into)?_____________________

How would you describe your child’s attendance (currently)?(circleALLthatapply)

Attending regularly Home‐schooled Some truancy Alternative school Suspended

Expelled Dropped Out GEDprogram

How would you describe your child’s achievement/grades in school? __________________________________

How would you describe your child’s attitude towards school/education? ______________________________

Disciplinary or behavioral issues at school? £ Yes £ No If yes, describe: ____________________________

______________________________________________________________________________________________________________________________________________________________________________________

Please check if your child has any of the following?

Special Education Accommodations or a 504? Please describe: ____________________________________
An Individualized Education Plan (IEP)? Please describe: _____________________________________

£ Diagnosed Learning Disability?	Please describe: _____________________________________
£ Receiving special services at school?	Please describe: _____________________________________

EMPLOYMENT:

Is your child currently employed? £ Yes £No

If employed, where are they working? _____________________ How long? ______________________ Does your child enjoy their current job? £ Yes £No

HOUSING:

Would you consider your housing to be: £ stable £ unstable If unstable, please describe: _________

___________________________________________________________________________________________

Please choose the one that best describes the current housing arrangement for this child:

Parent/Guardian owns home £ Parent/Guardian rents home
Child and family live with relatives/friends (temporary)
Child and family live with relatives/friends (permanent)
Homeless £ Transitional Housing £EmergencyShelter

How long has this child lived in the current living situation?_________________________________________

How many times has the child moved in the past two years?________________________________________

What else do you think is essential for us to understand about your housing/living situation?

___________________________________________________________________________________________

FOSTER CARE INVOLVEMENT:

Has your child ever been in foster care? £ Yes £ No £ Unknown

From ______ age to ______ age Reason:________________________________

Type of Placement: £ Familial Placement £ Non‐FamilialPlacement

Current Status: £ In‐Care £OutofCare

If Out of Care, the reason for leaving: £ Adopted £ Returned to Home £Emancipated

£ Ran away from care £ Other: __________________ FAMILY MENTAL HEALTH HISTORY

Please identify if any family members have had a history of any of the following mental health/drug abuse/legal concerns.

Family History	Depression	Anxiety	Bipolar Disorder	Schizophrenia	ADHD/ADD	Trauma History	Abusive Behavior	Alcohol Abuse	Drug Abuse	Incarceration
Self
Mother
Father
Sister
Brother
Maternal Uncle
Paternal Uncle
Maternal Aunt
Paternal Aunt
Maternal Grandmother
Paternal Grandmother
Maternal Grandfather
Paternal Grandfather
Biological Child

AdditionalInformation:________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________

ALCOHOL/DRUG ASSESSMENT:

Does your child use tobacco or smokeless tobacco? £ Yes £ No £Donotknow

Does your child use alcohol or drugs? £ Yes £ No £Donotknow

To your knowledge, has your child ever used medications (prescription drugs or over-the-counter medication) recreationally? £ Yes £ No £Donotknow

To your knowledge, has your child ever overdosed or passed out on alcohol or other drugs?

Yes £ No If yes, when was the last overdose? __________________________________________

Has your child ever experienced problems related to their alcohol use? £ Yes £ No Ifyes,pleasecheckareaanddescribeproblems:

Legal £ Social/Peer £ Work £ Family £ Friends £Financial

Pleasedescribe:__________________________________________________________________

If yes, have they continued to drink/use drugs? £ Yes £No

LEGAL INVOLVEMENT:

Is there a current custody case involving your child? £ Yes £ No Ifyes,pleasedescribebelow.

History of CPS involvement: £ None £ Past £ Current Pleasedescribebelow.

Please indicate by checking your child’s legal status below.

No Involvement £ No Involvement £ Probation | Length: ____________
Parole | Length: ____________ £ Charges Pending £ Prior Incarceration
LawSuitorotherCourtProceeding

Charges:_________________________Probation/ParoleOfficer’sName:________________________

Contact#:____________________________________________________

AdditionalInformation:________________________________________________________________________

___________________________________________________________________________________________

Has your child ever been abused or assaulted? £ Yes £ No IfYes,pleasecompletethechartbelow.

Type of Abuse	By Whom? (relation to a child, if any)	At What Age?	Was it Reported?
£ Sexual			£ Yes £ No
£ Physical			£ Yes £ No
£ Emotional			£ Yes £ No
£ Verbal			£ Yes £ No
£ Abandoned/Neglected			£ Yes £ No

Has your child ever been a victim of bullying? £ Yes £No

Do you worry about your child’s safety now? £ Yes £No

What else do you feel is crucial for us to know?

___________________________________________________________________________________________

___________________________________________________________________________________________ HISTORY OF VIOLENCE:

Has your child ever been accused of abusing or assaulting someone? £ Yes £ No If yes, please complete the chartbelow.

Type of Abuse	To Whom?	Age of your child?	Was it Reported?
£ Sexual			£ Yes £ No
£ Physical			£ Yes £ No
£ Emotional			£ Yes £ No
£ Verbal			£ Yes £ No
£ Abandoned/Neglected			£ Yes £ No

Has your child ever been known to bully other children? £ Yes £ No

What else do you feel/believe is important for us to know? __________________________________________

___________________________________________________________________________________________

STRENGTHS/RESOURCES/SUPPORTS:

What limitations does your child/ family have (if any)?______________________________________________

What strengths does your child/family have?______________________________________________________

What resources does your child have to help with your current problem?

___________________________________________________________________________________________ What experiences (past & present) will help you in improving the current situation?

___________________________________________________________________________________________

Who does/can your child count on for support? £ Parents £ Boyfriend/Girlfriend £ Siblings

Extended Family £ Friends £ Neighbors £ School Staff £ Church £ Pastor £ Therapist
Group £ Community Services £ Doctor £Other:_________________________________________

CURRENT NEEDS/GOALS

What do you feel is your child’s biggest need right now? ____________________________________________

What do you most hope to gain from coming to counseling?_________________________________________

If you were to pick three goals to work on, what would they be?

Goal1:_______________________________________________________________________________

Goal 2: _______________________________________________________________________________ Goal3:_______________________________________________________________________________

What else would you like for us to be aware of?

___________________________________________________________________________________________

INDIVIDUAL(S) COMPLETING ASSESSMENT

Printed Name (primary person) _____________________________________ Date: _____________________

Signature _________________________________________

Relationship to child _______________________________________

Printed Name (secondary person) ___________________________________ Date: _____________________

Signature _________________________________________

Relationship to child _______________________________________

Psychosocial assessment example

The first Psychosocial assessment sample is the social work psychosocial assessment. Social work assessments offer helpful information about the client’s requirements and the most effective ways to assist them. Your evaluations will also determine the priority of the client’s treatment, taking into account the client’s immediate need to protect themselves, their mental health, and any other relevant circumstances.

Family psychosocial assessment example

In the family psychosocial assessment example, it is essential to realize that the family environment is crucial to children’s growth. How a family operates significantly impacts the child’s ability to adjust psychosocially and their mental health. It has been found that an increased number of family psychosocial risk factors are associated with an increased chance of behavioral disorders in children. It may be helpful to target children with behavioral issues by identifying their families early on if they have specific psychosocial profiles associated with a higher risk of having children with behavioral problems. These families can then receive prevention and early intervention services.

Conclusion

The psychosocial assessment history is the first step in the psychosocial evaluation, and the mental state examination is the last step in the process. With the help of the psychosocial evaluation, the nurse can recognize a wide variety of psychological or social problems that, with the application of the appropriate treatment, have the potential to enhance the patient’s quality of life significantly. To offer the best possible care for their patients, nurses need to be able to conduct practical psychosocial assessments and recognize when it is necessary to consult with other medical professionals.

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What Is A Mental Health Assessment?

Mental health assessments are carried out either as part of the ongoing examination of patients with mental health conditions such as anxiety or depression or as part of the screening process for such conditions. They are also helpful in diagnosing brain diseases, such as Alzheimer’s disease, which is another purpose for them. If a person is experiencing trouble at work, school, or interacting with others in social settings, it may be time for them to get a mental health evaluation. A diagnosis of attention deficit hyperactivity disorder (ADHD), for instance, or a personality disorder may begin with evaluating the individual’s mental health as a component of the discovery process. Evaluations of the patient’s mental health may also be carried out if there is reason to suspect drug addiction.

Mental Health Assessment

A mental health assessment is a process in which a psychologist or psychiatrist collects information about a patient through tests and interviews to evaluate the patient’s cognitive functioning and abilities in a variety of areas and to predict the patient’s future behavior.

An examination of an individual’s mental health and social well-being is a psychosocial assessment. It examines the individual’s self-perception and capacity to operate normally in society. The purpose of the psychosocial evaluation is to understand the patient so that one may give the very best treatment and assist the person in reaching their full potential in terms of health.

Some examples of Psychosocial assessment tools for mental health include the following;

Identifying the patient
Chief grievance
Background of the presenting disease
Psychiatric background
Surgical or medical background
Medication record
Use of alcohol and drugs
Cultural appraisal
Financial assessment
Coping skills

Mental health diagnostic assessment

Your doctor will most likely conduct a mental health evaluation that consists of a mix of questions, a physical examination, and maybe a written questionnaire. These components are likely to be included in the evaluation.

1. Talk with your primary care physician (GP)

When your doctor conducts your mental health needs assessment, they will observe your appearance, how you talk, and your state of mind to see whether or not these factors provide any hints that may explain your symptoms. This will be unobtrusive, and you will likely be unaware that they are doing it.

The attending physician will inquire about your professional background, marital history, family history, and questions on your present social status and family history (what supports you have at home). They will be interested in learning about any traumatic experiences, as well as information on your upbringing and any problems you have had with alcohol or drugs. They could inquire about your religious views, goals, and life objectives.

Make an effort to respond to all the questions honestly and as correctly as possible. Your doctor will have the most incredible opportunity to arrive at a correct diagnosis with this information. Depending on the underlying medical condition, some of these questions could make you feel unhappy or angry. Because some mental health issues are difficult to identify, it is possible that you may not immediately get a definite diagnosis or explanation for your symptoms.

2. Physical Examination

In many cases, a mental health risk assessment involves a physical check. Your current and previous medical conditions are influenced by the medications you are now taking and will be reviewed by your doctor. You will also be questioned on whether or not anybody in your family has a history of mental illness or mental disorder.

The objective of the examination is to determine whether or not your present mental health problems are due to a physical reason.

3. Additional diagnostic procedures

If your doctor suspects a specific cause, such as anemia or a B12 deficiency, they may refer you to a laboratory for testing, including a blood test or a urine test. They may check your electrolyte levels or your thyroid function. A computed tomography (CT), an electroencephalogram (EEG), or a magnetic resonance imaging (MRI) scan could be performed on you if it is thought that you have an issue with your neurological system.

In addition, you can be given a standardized written questionnaire in the form of a mental health assessment form to fill out and a spoken examination. The spoken examination will mainly entail answering mental health assessment questions. In general, these examinations are aimed to measure the following queries, which encompass a full mental health assessment:

More particular difficulties, such as depression
How well you think, how well you reason, and how well you recall
How well you can carry out tasks necessary for everyday life such as eating, dressing, and shopping.

When conducting a child’s mental health assessment, clinicians will consider the child’s age but may ask them to draw drawings to explain how they are feeling, or they may show them photos and discuss how they make them think.

It is also essential to understand that a mental health expert utilizes a template to record the results of mental health assessments. In mental health assessment nursing, nurses utilize these nursing mental health assessment examples that indicate how a filled mental health assessment template looks.

1. Child Sample

Behavioral observations & mental status:

Alertness: Alert

Orientation: Fully oriented

Appearance: Congruent with age, well-groomed, and appropriate dress

Demeanor: Easy to engage, polite, cooperative, and good eye contact

Attention: Adequate to engage in conversation, although mild distractibility was noted on testing

Language: Fluent and without word-finding difficulty

Memory: Intact autobiographical memory

Motor: No motor abnormalities were observed

Empathy: Intact

Mood: Normal

Affect: Full and reactive

Thought process: Linear, logical, and goal-oriented

Thought content: Appropriate, with no psychosis, hallucinations, or suicidal or homicidal ideation

Impulsivity: Mild

Judgment: Good

Insight: Good

2. Adult mental health risk assessment template

This 65-year-old female test participant arrived by herself and drove alone. She seemed to be the age she claimed. She had a casually messy hairstyle and moderately unkempt clothing. She walked with a cane and looked to have a somewhat shaky stride (“I fell in my home lately, so now I walk with a cane.

She had a good sense of location and circumstance but had trouble with time (missing the day of the week by one, and at first, unsure of the year). Both hands had a little tremble, which became worse when the right hand was used to grasp things.

A hearing was somewhat compromised, with the client requiring some information to be repeated, while vision seemed acceptable for reading forms. The speech was halting, somewhat loud, with a flat tone, and there was obvious trouble finding the right words.

The effect was mainly flat yet labile (periodic crying spells when discussing current loneliness). Most days, she characterized herself as being “low.” She said that most of the time, she felt depressed. “I’m constantly alone anymore since my spouse passed away three years ago.”

She vehemently denied having any suicidal thoughts or tendencies. She mentioned having some memory issues, particularly concerning fresh material. She admitted to drinking “a couple – three or four glasses of wine” every night but did not think this was an issue when asked about her alcohol use (a worry mentioned in the physician referral).

In this latter area, insight seemed limited. Based on a hypothetical situation (“What would you do if you discovered a wallet on the floor in a supermarket?”), social judgment seemed to be primarily unaltered. Bring it to the customer service desk.

No formal thinking disorders or unusual thought content were present. Testing motivation and effort were inconsistent (I gave up quickly as test items became moderately tricky).

Mental health assessment examples

The use of evaluation tools may be beneficial for patients of all ages with a range of mental and behavioral health disorders. Here are ten tools for adults and children’s mental health, along with some well-known examples from each.

Worrying

The following tools for anxiety assessment can help you identify the kind of anxiety that applies to your patient’s symptoms and the severity of those symptoms.

Depression, Anxiety, and Stress Scale (DASS)
Generalized Anxiety Disorder Screener (GAD-7)
Hamilton’s Scale for Rating Anxiety
Zung Anxiety Index

2. Addiction.

All types of addictions, including those to drugs, alcohol, and gambling, have several treatment alternatives. Index of Addiction Severity (ASI), Drug Abuse Screening Test (DAST), and Alcohol Use Disorders are three effective methods for evaluating addiction.

Evaluation of the South Oaks gambling screen: Identification Test (Brief Addiction Monitor) (AUDIT-C)

3. Mood Problems

Since the symptoms of several mood disorders often overlap, assessment tools may help you identify which mood disorder your patient most closely resembles. To determine if your patient has the symptoms of bipolar disorder rather than borderline personality disorder or another illness similar to it, you could utilize the Mood Disorder Questionnaire and the Bipolar Spectrum Diagnostic Scale combined.

4. Depression

Different patients cope with depression symptoms in various ways. By employing depression screening tools, you may adjust consultations or tests to your patient’s needs. Examples of depression assessment tools include the Geriatric Depression Scale and the Zung Self-Rating Depression Scale.

5. Disorders of the Personality

A standard personality disorder exam called the Adult ADHD Self-Report Scale is used to evaluate the signs of adults who may have ADHD.

6. Suicide

When individuals display warning indicators, the intensity of suicidal thoughts may be assessed using tools like the Columbia Suicide Degree Rating Scale.

7. Trauma.

Trauma falls under several different categories. Instruments for recognizing trauma include the Post-Traumatic Stress Disorder Checklist and the Kessler Psychological Distress Scale.

8. Foodborne Illnesses

The Eating Disorder Diagnosis Scale may be helpful when dealing with suspected cases of anorexia, bulimia, or binge-eating disorder.

9. Personality

Behavioral health assessments aim to understand better the patient’s home life, mental health, daily activities, habits, and other factors. These tests’ data may complement and clarify information learned from other exams. Here are a few examples of behavioral assessment tools. Youth and Children’s Parental Stress Scale (10 points)

There are tools for assessing mental health that is not only for adults. Many screening tools aid in diagnosing and treating children and adolescents. Examples include the

Children’s RCADS Anxiety and Depression Scale, Revised
The Problem-Oriented Screening Instrument for Adolescents, The Mood and Feelings Survey, and the Traumatic Events Screening Inventory (TESI-C): Child
Pediatric Symptoms Checklist for the PTSD Symptom Scale (POSIT) (PSC)

Examples of mental health assessment include the following;

Mental health assessment online

Taking a screening test is one of the quickest and easiest ways to determine whether or not you are exhibiting symptoms consistent with a mental health disorder. There are many different types of screening tests available.

Anxiety and depression are two of the most common and treatable mental health conditions affecting many people. And there is always the possibility of recovery. However, not all of us pay enough consideration to the condition of our mental health regularly.

Through online self-assessments, users can conduct screenings for mood and anxiety disorders. These screenings aim to provide a safe and discreet method for individuals to check in on their mental health. In addition to this, they provide an assessment of the user’s mental health, information regarding whether the user’s assessment results are consistent with a mental health disorder, a summary of the signs and symptoms of treatable mental health disorders, and access to a variety of locally available treatment options that are of a high standard.

Mental health self-assessment

During a circumstance when you are evaluating your mental health, you will be asked questions about your routines, thoughts, and feelings. Additional in-depth questions about your symptoms, such as how they influence your day-to-day life, what makes them better or worse, and whether or not you have tried to manage them on your own in the past, may be asked of you during your appointment. Your doctor will also analyze your outer appearance and conduct, including the following: Are you someone who quickly loses your cool, or do you prefer to stay to yourself? Do you look me straight in the eyes while we speak? Are you talkative? How do you come across in comparison to other people the same age as you?

Mental health disability assessment

The inability to engage in any substantial gainful activity due to medically determinable physical or mental impairments that can be expected to result in death or which have lasted. It can be expected to last for a continuous period of not less than 12 months, which is meant by the term “disability.” This term is used to describe a person who is unable to engage in any substantial gainful activity.

Remember that just because someone has been diagnosed with a mental disorder does not always mean they are disabled or unable to function. If a person with severe depressive disorder can participate in “substantive gainful activity,” then they are not considered hindered by the law. The Social Security Administration (SSA) uses the term “substantial gainful activity” to refer to a certain degree of work. A person who is impaired should not, as a general rule, be able to engage in the functioning of the national economy actively. For instance, if a lawyer has a mental condition (and is unable to practice law successfully), but the SSA determines that the lawyer is nevertheless competent to work as a waiter, the SSA does not consider the lawyer to be legally handicapped. When conducting a disability evaluation, psychiatrists should be aware of the potential for vocational rehabilitation and employment incentives in addition to the available treatment options.

Mental health intake assessment

An intake assessment is a series of questions and considerations that medical experts go through to evaluate a patient’s current state of health and decide which treatment approaches are most likely to be effective. In most cases, this evaluation comes first before a patient gets any therapy for their mental health.

Conclusion

With the help of the mental health assessment, the nurse can recognize a wide variety of psychological or social problems that, with the application of the appropriate treatment, have the potential to enhance the patient’s quality of life significantly. To offer the best possible care for their patients, nurses need to be able to conduct practical psychosocial assessments and recognize when it is necessary to consult with other medical professionals.

If you need any help with mental health assessment, contact our nursing experts.

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Tag Archives: Psychosocial assessment

What is a psychosocial assessment?

Psychosocial nursing assessment and intervention

Psychosocial assessment tools

1. Screening

2. Diagnosis

3. Monitoring of symptoms and the results

Psychosocial Status Examination

Psychosocial assessment template

Psychosocial assessment example

Family psychosocial assessment example

Conclusion

What Is A Mental Health Assessment?

Mental Health Assessment

Mental health diagnostic assessment

1. Talk with your primary care physician (GP)

2. Physical Examination

3. Additional diagnostic procedures

1. Child Sample

2. Adult mental health risk assessment template

Mental health assessment examples

2. Addiction.

3. Mood Problems

4. Depression

5. Disorders of the Personality

6. Suicide

7. Trauma.

8. Foodborne Illnesses

9. Personality

Mental health assessment online

Mental health self-assessment

Mental health disability assessment

Mental health intake assessment

Conclusion

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