Psychosocial History and Evaluation

Order Description

Bio-psychosocial history and evaluation: SWI will use critical thinking and social work assessment skills to complete a bio-psychosocial history and evaluation with a
client. A psychosocial history covers many aspects. Information gathered includes areas related to psychological or mental health, social history and many other
socio-economic factors such as health, employment, finances, education, religion, stress and support networks, including friends and family, according to Loyola
University. The ability to assess a situation depends on gathering all related information. The psychosocial history helps collect the information needed to provide a
meaningful evaluation which determines treatment plans. The psychosocial history impacts treatment decisions for such areas as medical and mental health therapy.
Aspects such as family history of depression, previous suicide attempts, medication or drug use, work or family stress and types of resources, including family or
community help and finances, provide the evaluator with necessary information, according to Clarion University. Please carefully follow the outline.

-Psychosocial History and Evaluation

I. IDENTIFYING DATA: Name, age, sex, race, marital status, educational level, employment, referring source.

II. CHIEF COMPLAINT: In patient’s words, why did patient come to treatment?

III. HISTORY OF THE PROBLEM: Onset, frequency, under what circumstances does it occur. Intensity variation, what are the emotional components? What are the somatic
components?

IV. HISTORY OF FAMILY: Identifying data on parents, siblings, spouse, children, others living in the home. Also health, socio-economic status of each.

V. PATIENT DEVELOPMENT: Birth problems, childhood problems and traumas.
Education and employment achievements and failures. Religion, recreation, current life problems (i.e.) legal, out of work, illness. Alcohol – drug abuse.

VI. PSYCHO-SOCIAL: Attitudes towards family members, parental attitudes towards patient, parents age at patient’s birth, typical parental advice. (See below for Mental
Status Exam form which is to be included in your paper.)

VII. MEDICAL HISTORY: Current physical symptoms, major illnesses, psychiatric hospitalizations, etc., neurological symptoms.

VIII. FAMILY HISTORY OF PSYCHIATRIC DISEASE: Who, when, what, what neurological problems in family.

IX. MENTAL STATUS: Descriptive – appearance, motor activity, speech and though, rapport, psychiatric symptoms (i.e.) emotional, cognitive, somatic, perceptual, memory
functions.

Quantitatives – orientation, attention, concentration, memory, judgment, abstraction, perceptual motor, intellect. State whether or not the person is psychotic.

X. SUICIDE EVALUATION: Current plans, where, by what means, when. Past attempts: Is the patient really planning to do it.

XI. HOMICIDE EVALUATION: Same as above (suicide evaluation).

XII. CURRENT MEDICATIONS: Dosage, starting date.

XIII. PROBLEM LIST: Psychiatric, social, physical, other.

XIV. DIAGNOSIS:

Axis I Clinical Syndromes
Axis II Personality or Developmental Disorders
Axis III Physical Disorders or Conditions
Axis IV Psychosocial Environmental Problems
Axis V Global Assessment of Functioning
Current:Baseline:

XV. PROGNOSIS: