Adolescent Psychosocial Asessment
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14CHILD/ADOLESCENT PSYCHOSOCIAL ASSESSMENT
Date of appointment: ________________________
Time of appointment: ___________________________
Client Name: _______________________________
Age: _________ DOB: __________________________
Gender: Male Female Transgender Preferred Name/Nickname: ___________________________
Ethnicity: Hispanic Non‐Hispanic
Race: ___________________________
Name of Person completing form: __________________________ Relationship to client: _________________
PRESENTING PROBLEM
: (Briefly describe the issues/problems which led to your decision to seek therapy services).
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
How severe, on a scale of 1‐10 (with 1 being the most severe), do you rate your child’s presenting problems?
MOST SEVERE 1 2 3 4 5 6 7 8 9 10 LEAST SEVERE
PRESENTING PROBLEM CATEGORIZATION: (Please check all the apply and circle the description of symptom)
Symptoms causing concern, distress or impairment:
Change in sleep patterns (please circle): sleeping more
sleeping less
difficulty falling asleep
difficulty staying asleep
difficulty waking up
difficulty staying awake
Concentration:
Decreased concentration
Increased or excessive concentration
Change in appetite: Increased appetite
Decreased appetite
Increased Anxiety (describe): __________________________________________________________
Mood Swings (describe): ______________________________________________________________
Behavioral Problems/Changes (describe):
_____________________________________________________________________________________
_____________________________________________________________________________________
Victimization (please circle): Physical abuse Sexual abuse Psychological Abuse
Robbery victim Assault victim Dating violence Domestic Violence
Human trafficking DUI/DWI crash Survivors of homicide victims
Other: ______________________________________
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Parent category: Medical