Social History & Assessment Form - Wufoo [PDF]

Social History & Assessment Form 1

2

Social History & Assessment Form

Assessment & Recommendations

Name

First

Last

1. Information Source Client

Family

Referral source

Other

Hospital records

Reliability of information from client and family:

3. Primary Support Marital Status: *

Single

Married

Separated

Widow/er

Divorced

Sources of support include: *

Spouse

Extended Family Members

Other

None

Friends

Closest personal support or living relative to whom we can speak: *

First

Last

Street Address *

City, State, Zip *

Phone Number

###

###

####

Relationship *

Level of Support they are able to provide: *

Good

Adequate

Minimal

None

Marginal

4. Social Environmental Social/Environmental issues that contributed to current situation: *

Family Conflict

Lack of Services

Volatile Living Environment

Negative Peer Influences

None

Other

Religious Affiliation: *

Yes

No

Unknown

No

Unknown

Are there spiritual, cultural or ethnic issues: *

Yes

Is the client a victim of physical, sexual, or emotional abuse, vulnerable to abuse or an abuser? *

Yes No If yes, describe the nature of the abuse: *

If Yes, please explain: *

Was there prior treatment: *

Yes No

5. Education Last Grade Completed: *

Please Select Needs/problems in school/college *

Academic difficulty/failure

Education disruption

Conflict with peers/teachers

Special education needs

Illiteracy

Truancy

Aggression

Other

6. Military History Vetran *

Yes

No

Branch of service:

Dates of service:

Service-connected disability *

Yes

No

If yes, nature of disability: *

7. Economic/Financial Status Income sources and monthly amounts, if known:

None Employment income

Vetran's benefits

Family support

Social Security

Welfare benefits

SSI

Food stamps

Other

8. Housing Issues Homeless

Disruptive in placement

Temporary

Foster Care

Unsafe/inadequate

Other

9. Forensic/Legal Problems Current/Active: *

Arrest

Incarceration

Jail Hold

Pre-tTrail Evaluation

Incompetent for Trial

Juvenile Court Order

Crime victim

Persistent pattern of criminal behavior

None

Other

Previous involvement with criminal justice system: *

Yes

No

11. Family/Developmental History Are there family medical/psychiatric issues pertinent to client's illness/treatment? *

Yes

No

Do childhood or developmental problems impact the current situation: *

Yes

No

12. History of behavior/Illness/Disability, Treatment & Community Resources Utilization *

Withdrawn

Depression

Suicidal

Self-Injurious

Alcohol abuse

Substance abuse, other than alcohol

Aggression/violence

Hallucinations

Delusions

Resistance/denial

Paranoia

Chronic mental illness

Other Client's known or reported history of treatment and previously used services include: *

Mental health services

Substance abuse services

Mental retardation services

None

*

Outpatient

Inpatient

Other

Counseling

Medication

Day Treatment

Medicaid

Case Mgmt

Medicare

Residential

DFCS

Sheltered Workshop

YDC

VA

Other

Treatment Recommendations

Not Applicable

Explain (include providers, dates, length of service, etc):

Is there any history of non-compliance with: *

Medication

13. Client's Goals/Expectation during this admission: