Adolescent Psychosocial Assessment Form Page 3
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4CLIENT NAME:_____________________________
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Do you or have you ever struggled with eating issues such as binging, purging, compulsive overeating or going days
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without eating? If yes, please describe.______________________________________________________________
_____________________________________________________________________________________________
PSYCHIATRIC HISTORY:
Describe your personality (i.e. aggressive, calm, shy, high energy)_________________________________________
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Have you been in counseling before?
Yes
No If yes, what type and when:___________________________
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_______________________________________________________________________________________
__________
Have you ever been hospitalized for psychiatric reasons?
Yes
No If yes, where and when:_____
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_______________________________________________________________________________________
Listed below are a number of categories in which people commonly find some difficulties. Please indicate how you
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are affected in each area by circling the appropriate number (please circle only one number for each item).
NO
SOMEWHAT OF A
MODERATE
SERIOUS
SEVERE
PROBLEM
PROBLEM
PROBLEM
PROBLEM
PROBLEM
#1
#2
#3
#4
#5
Depression
1 2 3 4 5
Sudden Change in mood
1 2 3 4 5
(sadness, loss of interest, etc)
Anxiety
1 2 3 4 5
Lack of energy
1 2 3 4 5
(nervousness, panic, excessive worry)
Anger control problems
1 2 3 4 5
Not liking self
1 2 3 4 5
Hallucinations
1 2 3 4 5
Not liking others
1 2 3 4 5
(hearing voices/seeing things)
Thoughts of homicide
1 2 3 4 5
Withdrawal from others
1 2 3 4 5
Thoughts of suicide
1 2 3 4 5
*Problems with sleep
1 2 3 4 5
*Suicide attempts
1 2 3 4 5
Nightmares
1 2 3 4 5
*Obsessions or compulsions
1 2 3 4 5
Overly suspicious
1 2 3 4 5
*Serious trauma
1 2 3 4 5
Problems with boy/girlfriend
1 2 3 4 5
*Self-abusive behaviors
1 2 3 4 5
Problems with friends
1 2 3 4 5
Hyperactivity
1 2 3 4 5
Problems with gambling
1 2 3 4 5
Impulsivity
1 2 3 4 5
*Explain _________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Who do you rely on for support? (ie, spouse, parents, coworkers, etc) ___________________________________
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Parent category: Medical