Psychosocial Assessment Template

A psychological assessment template is a document which is aimed at a thorough understanding of an individual’s mental and social behavior. This can be a regular form which has to be filled in by the patient’s family members while being admitted, or it can be a more general survey conducted by any institution or organization. Relevant and well-researched questions must be an integral part of the questionnaire.

Sample Psychosocial Assessment Template:

Psychosocial Assessment Template

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Name of surveying institution or hospital]

[Stamp and seal of receiving official]

[This form must be filled up the immediate guardian of the patient., with relevant documents as needed]

Name of patient: _____________________________

Date of assessment: _____ [dd/mm/yy]

Date of admission: _____________________________

[dd/mm/yy] Social Security Number: ____________

Nature of problem: [please tick from the list provided below or specify clearly]

  • Abuse of narcotics
  • Mood swings
  • Bipolar Disorder
  • Depression
  • Personality Disorder
  • Violence
  • Sleep
  • Disorders
  • Others

Tendencies towards self destruction or suicide: ____________________________________ [Please mention any suspicious activities towards this as noticed in the patient in recent times]
Recent admittance into hospital: ___________________________ [Mention the last time the patient was admitted for psy-chosocial depression or deviant tendencies]
Age of patient at onset of psychosocial problems: ________________ [years]
Record of past treatment:

  • Treatment 1: ______________________
  • Treatment 2: ______________________
  • Treatment 3: ______________________

Currently living with: ____________________________ [mention the patient’s living situation]
Medical insurance policy number: _______________________ Last updated on: _____________________
Recent changes in behavior: _____________________________________

Probable reasons for the change: __________________________________________

Source of income: ____________________ Debts [if any]: ________________________________

[This section of the form is aimed at locating specific causes for the patient’s psychosocial behavior]

Current medical officer in charge of patient: __________________________

Signature of guardian: ______________________________________

Relationship with patient: ____________________________________

Date: _____________________________

Category: Assessment Templates

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