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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):

___________________________________________________________________________________________ ___________________________________________________________________________________________ PREGNANCY & BIRTH HISTORY:

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:_________________________________________________________________________

___________________________________________________________________________________________ ___________________________________________________________________________________________ HEALTH HISTORY

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:________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________ ___________________________________________________________________________________________ HISTORY OF ABUSE/NEGLECT:

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?

___________________________________________________________________________________________ ___________________________________________________________________________________________ What are you (and your family) already doing to improve 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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