Crawford consulting and mental health services, inc ADOLESCENT PSYCHOSOCIAL ASSESSMENT

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1 ADOLESCENT PSYCHOSOCIAL ASSESSMENT The following necessary information will help make your first session most productive, Signed consent is required from the parent(s) or legal guardian before treatment can be provided. If you are court-mandated to receive counseling, bring the court order or case plan. Please bring all documents to the first session. Thank you. Date of assessment: DEMOGRAPHICS Who is providing information for the assessment? Child/Adolescent Parent/Guardian/Representative Name Relationship Last Name First Middle Residence Address City State Zip Code Date of Birth Age Social Security Number Telephone (Home) (Cell) (Parent/Guardian) Sex Male Female PERSONAL HISTORY Why are you looking for treatment? What has been done so far to address these concerns? In what areas do you need help? Anger Management Depression Housing Trauma/Abuse Anxiety School Substance use/abuse Grief/Death/Loss Family Legal/Juvenile Justice Significant other relationship Employment Other

2 MENTAL HEALTH Have you had any of the following within the past 90 days? (Check all that apply) Suicidal thoughts Depression Panic attack Suicidal attempts Death in family Panic/phobia Self injury Hyperactivity Cruelty to animals Obsessive/intrusive thoughts Paranoia/Delusions Fire setting Thoughts of harming others Mood swings Poor sleep patterns Violence Anxiety Weight gain/loss Hallucinations (voices/visions) Have you ever been in counseling before? Yes No Date Location Counselor Are you currently taking behavioral health medications? Yes No If yes, please list Medication Dose Doctor Reason taking as prescribed? Have you ever taken behavioral health medications? Yes No Medication Dose Doctor Reason taking as prescribed? Have you ever been hospitalized for behavioral health reasons? Yes No Date Location Doctor What are your previous mental health diagnoses? Explain any family history of substance abuse: Have you used or are you currently using any drugs or alcohol? Yes No If no, skip to next section Do you feel that you should be cut down on your substance use? Yes No Have you ever felt bad or guilty about your substance use? Yes No Have you ever tried to stop and have been unsuccessful? Yes No Date Circumstances Have you ever had a drink or used drugs first thing in the morning to steady your nerves, get rid of a hangover, or get the day started? Yes No

3 Have you ever had a blackout while using drugs or alcohol? Yes No What consequences have you suffered because of you substance use? (Check all that apply) Financial Employment/School Physical health Legal Relationships Mental health Have you ever had any substance abuse treatment? Yes No Date Type Location/Counselor Did prior substance abuse treatment help? Yes No Please explain MEDICAL Who is your primary care physician? Doctor Address/Location Please indicate any medical problems you have had or currently have? (Check all that apply) Asthma Hearing impairment Sinus/Allergies Back/neck injury Heart Problems Speech impairment Cancer Physical impairment Visual impairment Developmental disability Seizures Diabetes STD Gastrointestinal Head injury Other Please list your current medications: Medication Dose Doctor Reason Taking as prescribed? FOR FEMALES Are you pregnant? Yes No If yes how many months? Have you given birth within the past 12 months? Yes No SOCIAL/VOCATIONAL/EDUCATIONAL What is your current grade? What school are you attending? What type of classes are you most involved in? Regular ESE Gifted

4 Check which behaviors are problematic: (Check all that apply) Tardy often Skipping class Failed grades Disruptive Defiant Poor performance Social problems Dropped out Suspended Absenteeism Repeated grades Expelled Are you currently employed? Yes No If yes what do you do? Are there any problems at work? Yes No If yes please explain: Who is your primary emotional support? Do you attend church or participate in other religious activities? Yes No LEGAL Have you ever been arrested in the past 90 days? Yes No Charge(s) Status/Disposition Court Date Are you court ordered for services? Yes No Name Phone Number What is your legal status? When is your next court date? Will you require a progress note for legal authorities? Yes No If yes: Name Location Phone FAMILY HISTORY Who is/are your primary caregiver(s)/guardian? My relationship with my caregiver(s)/guardian(s) is: Good Fair Poor Not applicable

5 How many siblings do you have? Brothers Sisters My relationship with my siblings is: Good Fair Poor Not applicable Are you currently in a romantic relationship? Yes No How many close friends do you have? RECOVERY ENVIRONMENT What is your interest and what do you do for fun? Who or what gives you hope? If you could change one thing about your family and yourself, what would it be?