Psychosocial Assessment Template
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Looking for a psychosocial assessment template?
In this article, we provide an overview of the psychosocial assessment tool and process, key assessment categories, questions to ask clients, and a free downloadable psychosocial assessment template that you can save to your electronic health record (EHR) for repeated use.
Using a psychosocial assessment template during the initial intake process is an ideal opportunity to gain key insights that will determine how to proceed in future therapy sessions with clients.
What is a psychosocial assessment?
Psychosocial assessment tools are used by mental health professionals, including counselors, nurses, and social workers, to examine a client’s background. These may also be called biopsychosocial assessments or biopsychosocial-spiritual assessments.
Think of the assessment like an interview, or a first therapy session, where the clinician asks a lot of questions to understand more about the client and what brought them to therapy.
These tools also provide insight into factors that may influence how clients present, such as their family history, relationship information, and why they are seeking support.
Generally speaking, a psychosocial assessment template will gather information in the following key areas:
Intake information
Intake information is typically completed by the client prior to their first appointment, and includes information about demographics, type of work or school, consent, emergency contact details, reason for seeking treatment, and additional background information.
Psychological information
This includes information such as:
- Presenting information/problem: These questions ask why the client is seeking mental health support. Clinicians may also ask the client to describe their symptoms, how long the problem has been going on, and the times or situations in which it occurs—in their own words.
- Previous mental health treatment: Including diagnosis history, treatment history, and key coping strategies.
- Treatment goals: The clinician may also ask the client what they hope to achieve through therapy.
Social information
This category includes:
- Gender and sexuality information, including pronouns
- Living arrangements
- Friends and significant relationships
- Employment or school status
- Hobbies, recreation, and what the client does for fun
- Cultural significance to the client, different ways their particular culture may view the problem/challenge, and community support
- Spiritual or religious beliefs
Biological information
This includes information such as:
- History: Family mental health history, any issues with substance use, trauma, marriage and divorce, siblings, estranged relationships, and criminal or legal issues.
- Medical information: Current conditions and treatment, medications, sleeping habits, movement, eating habits, and substance use.
Mental status exam
The assessment may include a mental status exam (MSE) of the client’s presentation, mood, thought patterns, affect, perception, insight, engagement, and behavior.
Risk and protective factors
This may include measurement-based care (MBC) tools that track progress and screen for suicidality, like the Ask Suicide-Screening Questionnaire (ASQ), which includes questions about the client’s risks, protective factors, and strengths.
Diagnosis
This includes the relevant ICD-10 code and diagnosis, and any relevant modifiers.
Examples of how to use the psychosocial assessment tool
Clinicians use psychosocial assessment tools in a variety of ways and settings, such as:
- School counseling
- Mental health outpatient treatment
- Substance use disorder inpatient treatment
- During an assessment in the emergency room
Depending on the setting and the age of the client, the therapist may also use various ways to collect the information, including:
- MBC tools, like a PHQ-9 to measure depression, an ASQ questionnaire to screen for suicidal ideation, or a GAD-7 to assess anxiety
- The clinician might draw a genogram diagram that describes the family and relationship dynamics
- The therapist might ask clients to rate a symptom on a certain scale
Example psychosocial assessment template (social work)
Name: RB
Age: 37
Pronouns: He/him
Reason for assessment: Client reported seeking treatment for depression after his girlfriend suggested it is becoming a problem in their relationship.
Presenting symptoms: Client’s PHQ-9 result of 15 indicates severe depression, including symptoms of hopelessness, insomnia, loss of pleasure, difficulty concentrating, loss of appetite, and low mood.
After completing the questionnaire, RB acknowledges that his results are concerning, and he agrees with his girlfriend that he needs treatment. This is the first time he has experienced depression since school, but he reported that it appeared situational and “went away” once he graduated.
The main stressors in RB’s life include a demanding job which he finds overwhelming. He reports difficulty concentrating at work and losing things at home, which upsets his girlfriend and causes challenges in their relationship. He reports that she frequently comments on his inattention, saying “you’re not paying attention,” and he is often late to social arrangements. Client has not been assessed for ADHD, but recently thought this might be causing these challenges.
Treatment goals: RB would like to pursue therapy to “feel more like himself,” and to develop new coping strategies. He has arranged to speak to his doctor about medication support. The client would also like to participate in an ADHD assessment.
Social information: Client has lived with his girlfriend for the last six months. He is employed full-time as a graphic designer, and reports being close to his family and having a strong network of supportive friends and coworkers. RB engages in game nights with friends and enjoys watching films with his girlfriend. Client does not have any spiritual or religious beliefs and does not align with any culture.
Biological information: RB is an only child and is close to his parents, who have been married for 40 years. Client reported no significant family history, but did mention his father has struggled with “feeling down” from time-to-time. Beyond difficulty sleeping and loss of appetite, the client has no significant medical history and does not take any regular medication. RB reported enjoying two beers with his girlfriend on weekends, but does not engage in recreational substance use or drinking beyond this.
Risk factors: Client had a negative ASQ screen, but is struggling with symptoms of severe depression, and some symptoms of inattention. However, he has many protective factors including a strong support network, loving relationship with his girlfriend, close relationship with his family, and regular employment.
Mental status exam: Client appears appropriately groomed, is slouched in their seat, reports a depressive mood, and has a flat affect with some lability when describing frustration with inattentive symptoms. He was attentive, oriented, coherent, maintained eye contact, and had normal speech, insight, and fair judgment. There was no evidence of abnormal thought content.
Diagnosis: Based on an assessment, ASQ screening, and PHQ-9 score, the client meets the criteria for major depressive disorder (F33.1).
Child psychosocial assessment differences
Mental health professionals who work with children or teenagers should complete a child psychological assessment PDF.
This will include more information about the child’s school, such as:
- What grade they’re in
- Which school they attend
- Any problems at school
- If they work part-time
- Supportive people and friends
- Challenges or stressors at school and how they are managing them
Geriatric psychosocial assessment differences
When interviewing elderly clients, the assessment is called a geropsychiatric assessment or comprehensive geriatric evaluation.
These assessments pay particular attention to comprehensive management, any decline in health and functional status, impending changes to living environments, and may involve consulting with family members. Mental health professionals who conduct assessments on this population should have specific expertise in treating elderly people with a range of physical and psychosocial needs.
How to use the psychosocial assessment template in your practice
We’ve provided a psychosocial assessment template at the top of this article that you can download and use in your practice. You can print it as is or save it to your computer, to adjust or fill out electronically—depending on your preferences.
The psychosocial assessment template is organized by section so you can easily retrieve your notes in your EHR when you need them.
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