COLUMBUS PSYCHOLOGICAL ASSOCIATES, L.L.P.

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COLUMBUS PSYCHOLOGICAL ASSOCIATES, L.L.P. 2325 BROOKSTONE CENTRE PARKWAY / COLUMBUS, GA 31904 PHONE: (706) 653-6841 FAX: (706) 653-7843 Adult Outpatient Psychosocial History Psychosocial Self-Assessment (To be completed by client) Name: Date of Birth: Age: Gender: Race: Referral Source: Self Physician (name) other Reasons For Seeking Treatment: I am seeking treatment at this time because: I have been having problems like this since My family/others want me to seek treatment because: Family History: Current marital status of my parents: ( ) Married ( ) Divorced ( ) Separated ( ) Widowed ( ) Single Parent My father s age, if living His occupation His highest education His health status If deceased, his age at death and cause of death Your age when he died Any history or mental illness or addictions in my father: My mother s age, if living Her occupation Her highest education

Her health status If deceased, her age at death and cause of death Your age when she died Any history of any mental illness or addictions in my mother My siblings: Brother/Sister Age Occupation History of Mental Illness/Addictions 1. 2. 3. 4. Do you have stepparents? If yes, rate your current relationship with them ( ) very close ( ) distant ( ) other Rate your current relationship with your biological parents: ( ) very close ( ) distant ( ) other Rate your current relationship with your siblings: ( ) very close ( ) distant ( ) other Rate your current relationship with your extended family: ( ) very close ( ) distant ( ) other List any other family members who may have a history of mental illness or addiction: Relationship to me Type of problem Childhood Memories: I was born in I was reared in Family s socioeconomic status: ( ) high ( ) medium ( ) low Stability of home ( ) very stable ( ) not too stable ( ) unstable My primary caretaker ( ) mother ( ) father ( ) siblings ( ) grandparents ( ) aunt/uncle ( ) other

Describe any positive or negative memories that you have about your childhood including physical or emotional abuse: Developmental History: To my knowledge, I had a normal birth, delivery, and normal early childhood development (that is, I walked, talked, etc., about on time). If no, please explain: Education: I completed the grade, or years of college with a degree in Did you like school? ( ) Somewhat Did you get good grades? ( ) Somewhat What were (are) your strengths and weaknesses in school? Strengths Weaknesses If currently in school, which school? Any grade failures? Were you ever diagnosed with a learning disability? Were you ever diagnosed with attention deficit disorder or hyperactivity Any history of behavior problems, i.e., suspensions, truancy, fighting? If yes, please explain Employment: I am employed I am employed with My job title is Years Employed Summaries Employment History Is your employer aware of a need for treatment? If yes, does your employer have any special requirements for you to return to work? Finances: Do you have a problem with managing money? Are you currently experiencing financial distress? Please comment

Social/Leisure: Leisure activities I enjoy, and how often I participate in them: Type How often My level of interest in these activities has changed lately: How are these changes and your problem related? I have enough close friends who provide me with support. Please comment: Sexual History: My sexual orientation is: ( ) heterosexual ( ) bisexual ( ) homosexual Age of first sexual experience Any sexual abuse or trauma (either as a victim or a perpetrator) as a child or as an adult: Has your interest in sex changed lately? Marital Information: Marital status: ( ) Married ( ) Single, never married ( ) Divorced ( ) Widowed Spouse s name: Age, if living Occupation Health status: If deceased, age at death and cause of death Years married Relationship with spouse: ( ) Satisfactory ( ) Unsatisfactory ( ) Needs Improvement Please comment My spouse has a history of mental illness: My spouse has a history of addiction: If previously married, state how long you were married, and reason relationship ended: How long married Reason for ending My children and step-children from all relationships: Name M/F Age Relationship with me Comments

Living Situation: I currently live with Other people living in my house (if any) are: I live in a ( ) House ( ) Apartment ( ) Trailer that I ( ) Own ( ) Rent If other living accommodations are used, please describe: Military History: Branch of service: Number of years served: Rank at discharge: Type of discharge: ( ) Honorable ( ) Dishonorable ( ) Medical ( ) Other Comments on your time of service, including promotions, demotions, problems, successes, etc.: Cultural/Religious: In what religion, if any, were you raised? Are you currently active in any religion? If yes, please comment How has your cultural/ethnic/religious heritage or background affected you or your family? Describe your spiritual orientation: Describe what gives meaning to your life: Legal History: Do you have an arrest record (including DUIs)? Date Type of offense Result Any other legal involvement (pending suits, bankruptcy, divorce, custody issues)? Psychiatric: I have problems with depression: I have problems with anxiety: Describe any other problems: Previous inpatient or outpatient treatment: Dates Where Treatment/Medications Prescribed

Alcohol and Drug History: I have abused alcohol: If yes, complete the following: My pattern of use is The last time I had a drink was I have used alcohol months/years I have periods while drinking that I cannot remember: I have experienced jitteriness, anxiety or nervousness when I don t drink: I have abused drugs (including prescription drugs): If yes, complete the following: Type: My pattern of use is My last use was I have used drugs for months/year History of withdrawal symptoms My drinking and/or drug use has had an effect on the following life areas: ( ) Family ( ) Social ( ) Legal ( ) Job ( ) Physical ( ) Financial ( )Emotional Previous inpatient or outpatient treatment for drugs and/or alcohol: Dates Where Treatment/Medications Prescribed Any involvement in AA, NA, support groups, etc? Self-Assessment: I see my personal strengths and weaknesses as: Strengths Weaknesses Trauma: Any abuse (verbal, physical, or sexual)? When? By Whom? Any natural disasters (fire, tornado, earthquake, etc.)? When? Any deaths or major losses? When? Any other trauma? When? Medical: Any chronic/current medical problems?

Any allergies? Any surgeries? I am currently taking the following medications: Date of last physical examination, doctor s name, and the results of the examination: Client s Signature Date

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