Adolescent Psychosocial Assessment Form Page 4
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2
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4CLIENT NAME:_____________________________
4
BEHAVIOR:
Do you have concerns about your behavior?
Yes
No
If yes, explain ______________________________
•
______________________________________________________________________________________________
Describe any changes in your behavior in the past year___________________________________________________
•
______________________________________________________________________________________________
What disciplinary methods are commonly used and how effective are they? __________________________________
•
______________________________________________________________________________________________
Who usually disciplines you? ______________________________________________________________________
•
Are you using illegal substances or do your parents/guardian suspect you of this behavior?
Yes
No If yes,
•
explain: _______________________________________________________________________________________
Please complete the following regarding your drug/alcohol use history:
SUBSTANCES USED/ABUSED
AGE OF
YEARS OF
LAST DATE
AMOUNT
FREQUENCY
ST
1
USE
USE
USED
OF USE
(such as alcohol, marijuana, vicodin, etc)
OF USE
What is your substance of preference?________________________________________________________________
Please answer the following questions:
Yes
No
I have overdosed from drugs/alcohol.
Yes
No
I have felt bad or guilty about my use of drugs/alcohol.
Yes
No
Family members complain about my drug/alcohol use.
Yes
No
My drug/alcohol use has created problems for my family.
Yes
No
I lost friends because of my drug/alcohol use.
Yes
No
I neglected my family because of my drug/alcohol use.
Yes
No
I got in trouble at work/school because of my drug/alcohol use.
Yes
No
I got in physical fights while under the influence of drugs/alcohol.
Have you received treatment for a substance abuse problem before?
Yes
No If yes, explain______________
•
______________________________________________________________________________________________
Were you ever arrested, convicted or placed on probation?
Yes
No
If yes, describe below:
•
Age___________ Offense_____________________________________________________________________
Age___________ Offense_____________________________________________________________________
Are you currently on Probation/Parole?
Yes
No
If yes, describe and give PO name:_______________
•
____________________________________________________________________________________
_________________________________________________________
_____________________________
Parent/Guardian Signature
Date
5/2012
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