Example Of A Psychosocial Assessment (Page 3 of 8) in pdf

Example Of A Psychosocial Assessment Page 3

Suicidal/Homicidal Ideation

Is there a suicide risk? ___ No ___ Yes

___ Previous attempt (When: _____________________________________________)

___ Current plan ___ Means to carry out plan ___ Intent ___ Lethality of plan

Is the patient dangerous to others? ___ Yes

____ No

Does the patient have thoughts of harming others? ___ Yes

___ No

If yes: Target: __________________________________________________________

Can the thoughts of harm be managed? ___ Yes ___ No

___ Current plan ___Means to carry out plan ___ Intent ___ Lethality of plan

High risk behaviors

___ None ___ Cutting ___ Anorexia/Bulimia ___ Head Banging

___ Self injurious behaviors

___ Other: _____________________________________________________________

Abuse Assessment

In the past year has the patient been hit, kicked, or physically hurt by another person?

________________________________________________________________________________

__________________________________________________

Is the patient in a relationship with someone who threatens or physically harms them?

________________________________________________________________________________

__________________________________________________

Has the patient been forced to have sexual contact that they were not comfortable with?

________________________________________________________________________________

__________________________________________________

Has the patient ever been abused? ___ Yes ___ No. If yes, describe by whom, when and how.

________________________________________________________________________________

________________________________________

Example Of A Psychosocial Assessment Page 3