Psychosocial Assessment
Conduct a psychosocial assessment to gauge a patient’s mental and social well-being and create a therapy plan that restores them to a better state physically, mentally, and socially.
Fact Checked by Nate Lacson.
What is a Psychosocial Assessment?
A Psychosocial Assessment is a type of examination often used in mental healthcare and social work to gauge patients, specifically their mental and social states.
This is typically conducted by a psychologist, psychiatrist, therapist, counselor, nurse, or social worker, and they do so in the manner of an interview. The conductor will ask patients several questions covering several aspects of their lives, such as their current living situation, their educational attainment, their employment status, if they have a history of substance abuse, if they have had run-ins with the law, their relationships, if they have a support system to rely on, their childhood experiences, and medical history, especially concerning their mental health.
The reason why a psychosocial assessment will focus on several aspects of a person’s life is that it operates on the belief that their experiences and the current states of those aspects can provide preliminary explanations for their current mental and social well-being. This information will also determine what type of therapy or counseling the patient needs and help their assigned mental health professional determine what should go into a tailor-fitted therapy plan for them.
Printable Psychosocial Assessment
Download this Psychosocial Assessment to gauge a patient’s mental and social well-being
How does a Psychosocial Assessment work?
A psychosocial assessment can be conducted in two ways:
- You can hand a psychosocial assessment form to your patient and have them fill it out.
- Or, you can conduct it like an interview.
Psychosocial assessments come in different forms. Some might even have sections where the healthcare professional using it will note down specific observations while conducting the interview (e.g., if the patient looks sleepy, if they are not attentive, if they are well-groomed, if they make eye contact). How this will be conducted depends on what a psychosocial assessment form contains. We recommend that you conduct it as an interview so you can ask the patient to elaborate as you converse.
The template we have has portions for the conductor to note down their observations, so it should be used in an interview format.
In order to fill out the template, you just need to follow the structure:
- Ask for the patient’s full name and date of birth.
- Presenting Problem: ask the patient what brings them here today.
- History of their present illness: ask the patient when they have been dealing with their problem.
- Past psychiatric/psychological history: ask about their psychiatric/psychological history, like if they have been treated for mental illnesses before or if they’ve been admitted to a psych ward.
This also has a list of mental health symptoms they currently have. Have them rate each symptom between 0 to 3. 0 means “not present,” 1 means “mild,” 2 means “moderate,” and 3 means “severe.”
You can also ask them how these symptoms have affected their life.
- Past medical history: ask what physical illnesses and injuries they’ve been treated for in the past and if they have undergone surgery for specific problems.
You must also ask about their current medication and if any non-mental health condition they have now is causing them pain and difficulty.
This part also contains a substance abuse list. Ask them if they currently use any of the substances on the list. If they have stopped, ask what they used before. There are also questions asking them if they have blacked out due to substance abuse, if they’ve been treated for substance abuse before, if they have been involved in recovery/support programs, if they are aware of triggers that make them use these substances, and if they’ve had legal trouble due to substance abuse.
There is also a short section asking them about binging on food, not eating at all, vomiting on purpose, and using laxatives.
- Allergies: ask if they have any allergies.
- Suicidal/homicidal ideation: ask them if they’ve had thoughts of self-harm or causing harm to others. Ask them if they are able to manage these thoughts or not.
You can also ask if they have guns at home.
- Family history: ask them about what their family was like growing up, what their current relationship with their family is, and the medical history of their family (if members had mental illnesses, substance abuse problems, hereditary illnesses, etc.).
- Marital and social relationships: ask about their relationship status. If they are married, ask how they view their marriage and relationship with their spouse and children. If they have been married before, ask how many times they have been married and what caused them to annul/divorce.
Also, ask if they have friends, if they participate in social activities, and if they have support systems.
- Educational history: ask what educational attainment they have and if they’ve had behavioral problems in school.
- Work history: ask if they are currently working. If they are currently working, ask what their job title is, what company they are working for, and how long they have worked for their employer. Ask how they feel about their work.
- Trauma: Ask if they have been physically threatened and/or hurt by another person and if they’ve been sexually abused.
- Legal status: ask about their current legal status or if they have been involved in legal trouble before.
- Sexuality: ask if they are heterosexual, homosexual, or bisexual. Ask them if they view themselves as male, female, or non-binary. You may also ask them if they are accepted for their sexual orientation and gender identity by the people closest to them and if they have faced discrimination.
- Spirituality: ask about their religious beliefs, if any. Also, ask if they participate in any religious groups or activities. Ask about how they feel about their beliefs, especially in terms of how they were brought up with them. Also, ask if they have been discriminated against for their beliefs.
- Cultural background: ask what their race/nationality is and ask if they have ever been discriminated against for their race/nationality.
- Financial background: ask about their financial situation.
- Coping skills and mechanisms: ask about how they cope when distressed, especially by their current problem.
- Interests and abilities: ask about what they like, their hobbies, what they’re good at, and what gives them pleasure.
- Mental status assessment: this is a series of observations you should note down while interviewing the patient. You will look at their orientation, appearance, mood, attitude, delusions, hallucinations, thought processes, thought content, cognition, and knowledge.
- The last part is for noting down any insights you have and areas of concern you might have identified based on your patient’s answers.
That’s it! It’s a little long, but it should be comprehensive enough to give you the necessary groundwork for your therapy program and plan.
Psychosocial Assessment Example
Now that you know what a psychosocial assessment is, who normally conducts it, how it is conducted, and what it asks for, it’s time to see our psychosocial assessment template! It contains all the sections that we mentioned in the previous section, and they are arranged accordingly.
If you like what you see and believe this psychosocial assessment template will benefit your mental healthcare work, then, by all means, download it from our platform. It’s free! You can print it and fill it out with a pen or go paperless and engage with the editable portions of the PDF file.
Download this Psychosocial Assessment Example (Sample) here:
When is it best to conduct a Psychosocial Assessment?
There are several appropriate times when psychosocial assessments are conducted, but they are mostly in healthcare and social work settings!
Healthcare professionals who specialize in treating the mental health of patients often conduct psychosocial assessments during initial encounters to get the necessary preliminary information regarding their patient’s mental well-being and social state. The reason why it’s essential that this is conducted during the initial encounter is because it provides the professionals with baseline information that can serve as grounding for their therapy, counseling, or psychiatry programs and treatment plans. This information might reveal the factors that are impacting the patient negatively, and these factors can be the focus of the treatment plan moving forward.
For professionals who specialize in treating patients for physiological matters, psychosocial assessments are conducted during treatment to gauge how their current conditions are impacting their mental health. It’s possible that physiological conditions can horribly impact a patient’s mental well-being, especially if the condition is debilitating and is preventing them from carrying out their duties, activities of daily living, and what they love and enjoy. By gauging them through a psychosocial assessment, professionals can include certain interventions and treatments for any mental health issues that emerged due to their patient’s physiological conditions as part of the patient’s current treatment plan.
What are the benefits of conducting Psychosocial Assessments?
It can help professionals understand a patient’s situation.
One of the great things about psychosocial assessments is that they are always divided into several sections, each one covering a different aspect of a person’s life, from their educational background to their family life. It even covers bits of their past and sees how anything from their past got carried over today in some shape or form. By covering these aspects, healthcare professionals will have enough information to serve as the basis for their psychiatry, therapy, or counseling program and tailor-fit their approach based on what they’ve gleaned from the information on the assessment form.
It can help detect problems early on, and it can help with the development of treatment plans.
Speaking of tailor-fitting approaches to patients, a psychosocial assessment won’t just provide the professional with enough information to get to know the patient. The information can help identify signs of certain problems. By detecting problems early, professionals can act fast to prevent the problem from getting worse and work to whittle its impact on the patient until they are in complete remission (if at all possible). Identifying signs or confirming problems early should help professionals develop a personalized treatment plan for their patients that focuses on specific needs.
It can be used to monitor patients down the line.
Let’s stipulate that you have developed and implemented a treatment plan for your patient. Obviously, you’d want to know how they’re doing and if your treatment plan is working. One way to check on them and your treatment plan at the same time is to conduct a psychosocial assessment again, though, this time, you have to tweak your questions to accommodate the fact that they are undergoing treatment. If their answers indicate that they’re improving or they are in a much better place, then it’s safe to assume that your treatment plan is working If not, you might want to adjust it based on their current answers and see if the changes will work.
Commonly asked questions
Psychologists, psychiatrists, counselors, therapists, social workers, and nurses.
Yes, just like any other clinical document. Healthcare professionals are obligated by law, especially by HIPAA, to ensure that they protect the privacy of a patient’s health information, including the information indicated on psychosocial assessment forms.
Since the form is long and covers multiple aspects of a person’s life, it could take at least 60 minutes to complete it. You will be asking multiple questions via interview format, after all. Don’t be surprised if it takes longer than 60 minutes.
