Psychosocial Assessment Form - Florida Department Of Health
ADVERTISEMENT
1
2
3
4I~
Psychosocial Assessment
Directions: After the assessment interview, check off items that apply. Write
infOrmation obtained from the interview. If subject
area
is not applicable, write NIA.
Status:
Appearance and General Behavior
Name:
IDNo:
Date of Birth:
-------------------------------
Date of Initial Assessment:
0 Appropriate attire
0 Oriented to time, place and person
0 Guarded/avoidant
0 Uncooperative
0 Clothing disheveled
0 Disoriented/confused
0 Poor hygiene
0 Pressured speech
0 Agitated
0 Cooperative
0 Psychomotor retardation
0 Other:
Comment--------------------------------------------------------------------------------------
Mood/Affect
0 Normal mood
0 Appropriate to content
0 Adaptable
0 Flat affect
0 Angry/hostile
0 Labile
0 Irritable
0 Inappropriate to content
0 Euphoria/elated
0 Anhedonia
0 Depressed/sad
0 Anxious
0 Other: - - - - - - - - - - - - - -
Comment: __
~~--~~~------------------------------------------------------------------------
General Functioning/Behavior
0
Able to abstract
0 Potential for suicidal ideation
0 Impaired concentration memory
0 Logical/goal directed
0 Limited insight
0 Social withdrawal/isolation
0 Alert
0 Poor anger management
0 Articulates needs and issues
0 Fully oriented
0 Low self esteem
0 Impaired judgment
0 Poor impulse control
0 Decreased attention span
0 Other: ---------------------------
Comment: __________________________________________________________________________________ _
Coping Mechanisms/Resources
0 Able to live independently
0 Adequate problem solving skills
0 Able to ask for assistance
0 Insight oriented
0 Able to articulate needs/concerns
0 Adequate coping/stress management skills
0 Good judgment
0 Able to reach out to others
0 Takes responsibility for actions
0 Able to make decisions
0 Appropriate emotional expression
0 Other: ---------------------------
Comment:--------------------------------------------------------------------------------------
Living Status
0 Independent
0 Lives with family
0 Lives with partner
0 Lives with friends
0 Group/institutional
0 Homeless/shelter
0 HUD housing
0 Other: - - - - - - - - - - - - -
Comment--------------------------------------------------------------------------------------
Support Network/Resources
0 Family
0 Friends/co-worker
0 Significant other
Comment:
0 Substance abuse treatment
0 None
0 Community support group/agencies
Perception of Support System as Reported by Participant:
0 12 step program: -------------------
0 Mental health agency: -----------------
0 Religious/social affiliation
Receiving Services from Other Agencies/Service Providers: 0 Yes
0 No
Agencies: -----------------------------------------------------------------------------
Significant Cultural/Religious Issues: 0 Yes
0 No
DH 3184, 11/G8
Stock Number. 5744-000-3184-6
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Dh-1622 - Occupational Exposure Record For A Monitoring Period - Florida Department Of Health
Legal
Form Dh 3203 - Authorization To Disclosure Confidential Information - Florida Department Of Health
Legal
Form Fdacs-03428 - Written Accident Report Form - Florida Department Of Agriculture And Consumer Services
Business
Form Dr-144 - Gas And Sulfur Production Quarterly Tax Return Form - Florida Department Of Revenue
Financial
Related Categories
Parent category: Medical