Psychosocial Assessment

What brought you here today?

Sibling Name(s), Gender, Age, Birth Order, Family Type (traditional, blended, single parent), Sibling Characteristics, Relationship (conflict/close)

A lot of families are influenced by where they come from, even after many generations. To help me understand your family can you telling a bit about the last 3 to 4 generations of your family in regards to where they lived and what religious or political beliefs that might have been important in their lives?

Do you know why your family immigrated to Canada? What it a push or a pull?

Is there any specific belief system that you follow that I need to be aware of?

Did religion / spiritual practice play a part in your upbringing?

What was your role in the family?

Tell me about your MOTHER, step mother and/or other significant female care providers?

Tell me about your FATHER, step mother and/or other significant female care providers?

Tell me about your earliest childhood memory.

Any significant family events during your growing up years?

How did your family handle conflict when you were growing up? How did your family communicate with each other?

What do you like and dislike about your family?

Extra or other information

Medication(s)

Exercise - What do you do for exercise?

Sleep - Any concerns? Hours/Night

Sex Life:

Alcohol Intake:

Drugs:

Have you ever had a period of heavy alcohol or drug use? Please describe.

Has any member of your family had a period of heavy alcohol or drug abuse, past or present? Pease describe.

Has or does drug and alcohol use interfere with or negatively affect your life?

Addiction details

How would you describe yourself emotionally?

Details

Hospitalization / treatment for psychiatric problems

Any memory and/or cognitive problems?

What significant problems or stresses are you facing at the present time?

Details

List any significant relationships in your life:

Sexual Orientation & Attraction / Gender Identity / Gender Expression

Other

Current employment/ job description?

Why?

Describe any legal (criminal) problems you have ever had.

Describe any violent behaviour you have ever exhibited.

If yes,

What was and was not helpful from your past counselling experience?

Additional details

Tell me about your hobbies & interests? What do you do for fun and relaxation?

If you were granted 3 wishes what would they be and how might they change your life

What would you like to achieve in our working together?

Have I missed anything that you think I should know?

Counsellor Comments/ Notes

Family history

Medical history

lifestyle

Addictions

Emotional and Mental Health

Risk Assessment

Relationship history

Relationship history

Career

legal history

Support systems

Treatment Goals

Recommendations