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Psychosocial Assessment Form Template

A Comprehensive Tool for Assessing Emotional Well-Being

If you're struggling to evaluate a patient's emotional state, our Psychosocial Assessment Form Template is your solution. Designed for mental health professionals, this template provides a clear and structured way to assess various aspects of mental well-being. With benefits like streamlined data collection, improved patient communication, and customized insights, this template helps you deliver effective care. You can easily adapt this user-friendly format to meet specific needs, ensuring compliance with WCAG standards for accessibility. Try out the live template and simplify your assessment process today.

Use this Template (FREE) Live Preview
Full legal name
Date of birth
Primary language
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Email address
Mobile phone number
Emergency contact full name
Emergency contact phone number
Is it okay to leave a voicemail with appointment details on this number?
Yes
No
Primary reason for seeking support today
Brief description of your current concerns
How long have these concerns been present?
Less than 2 weeks
2-8 weeks
2-6 months
6-12 months
More than 1 year
Prefer not to say
How much do these concerns interfere with your daily life?
Very difficult
Difficult
Neutral
Easy
Very easy
Have you ever been given a mental health diagnosis?
Yes
No
Prefer not to say
Are you currently taking any psychiatric medications?
Yes
No
Please list current medications and dosages (if any)
In the past 2 weeks, have you had thoughts of harming yourself?
Yes
No
In the past 2 weeks, have you had thoughts of harming others?
Yes
No
Have you ever attempted suicide?
Yes
No
Prefer not to say
Protective factors you have right now (select all that apply)
Supportive relationships
Responsibility to family or dependents
Belief system or spirituality
Employment or school engagement
Pets or companion animals
Effective coping skills
Access to care
Prefer not to say
Other
Please Specify:
In the past 12 months, which substances have you used? (select all that apply)
Please Specify:
Have others expressed concern about your substance use?
Yes
No
How often has substance use interfered with your responsibilities in the past 3 months?
Very rarely
Rarely
Sometimes
Often
Very often
Current medical conditions or significant health concerns
How would you rate your sleep quality over the past 2 weeks?
Poor
Fair
Good
Very good
Excellent
Current housing situation
Stable housing (own/rent)
Staying with friends or family
Temporary housing or shelter
Homeless or unsheltered
Transitional/supportive housing
Institutional setting (hospital, treatment, justice)
Prefer not to say
Employment status
How difficult is it for you to pay for basic needs (e.g., food, housing, utilities)?
Very difficult
Difficult
Neutral
Easy
Very easy
In the last 12 months, did you worry that food would run out before you had money to buy more?
Yes
No
Prefer not to say
How satisfied are you with your social support?
Very dissatisfied
Dissatisfied
Neutral
Satisfied
Very satisfied
Significant life stressors in the past year (select all that apply)
Do you consent to receive email or SMS reminders and messages about appointments?
Yes
No
Your goals for services or what you hope to achieve
Type your full name as signature
Date signed
I confirm that the information provided is accurate to the best of my knowledge.
True
False
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paper art illustration featuring a psychosocial assessment form template for FormCreatorAI article

When to use this form

Use this form at intake, during treatment planning, or when a client experiences a major change. It suits therapists, social workers, case managers, and school counselors who need a clear picture of strengths, stressors, and risks. For new clients, pair it with the PHQ-9 & GAD-7 form to screen mood and anxiety while you capture relationships, work, housing, and coping. In medical or complex cases, combine it with the Biopsychosocial assessment form to align psychosocial needs with medical history for coordinated care. It also fits telehealth check-ins, crisis stabilization follow-ups, and discharge planning, where a structured snapshot helps you set goals, identify supports, and document next steps.

Must Ask Psychosocial Assessment Questions

  1. What brings you in today, and what change do you want to see in the next 30-60 days?

    This focuses the interview on your priorities and creates measurable, time-bound goals. Clear goals also keep the plan realistic and help you evaluate progress at follow-up.

  2. Over the past two weeks, how have your mood, anxiety, sleep, and energy levels affected daily life?

    This captures severity and impairment across key domains, which guides level of care. If you want to track day-to-day patterns between visits, pair your responses with the Mental health journal form.

  3. Have you had any thoughts of harming yourself or others, or behaviors that put you at risk (substance use, unsafe situations)?

    Direct questions reduce missed warning signs and allow immediate safety planning. Your answers inform triage, means restriction, and whether to involve supports.

  4. Who are your key supports, and what is your current living, work, or school situation?

    Support systems and environments are major protective or risk factors that shape outcomes. This helps you plan referrals for housing, employment services, or academic accommodations.

  5. Have you ever had periods of unusually high energy, little need for sleep, racing thoughts, or impulsive spending or risk-taking?

    Screening for manic symptoms prevents misdiagnosis and unsafe treatment choices. When indicated, you can add the Young mania rating scale (ymrs) form for structured scoring.

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