Psychosocial History Form

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EMERGENCY NOTICE: If you are experiencing a mental health emergency, please call 911 or go to your nearest emergency room. You may also call or text 988 to connect with the Suicide & Crisis Lifeline, available 24/7.

Full Legal Name*

Date of Birth*

Month

Day

Year

Age

Phone*

Email*

Relationship Status*

Religion*

Number of people present in your household:*

Emergency Contact Name*

Relationship to Client*

Emergency Contact Phone*

Emergency Contact Email*

Primary Care Physician Name

Primary Care Physician Clinic/Agency/School

Primary Care Physician Phone

Primary Care Physician Fax

Primary Care Physician Email

Presenting Concerns

Primary Reason(s) for seeking therapy*

When did these concerns begin and how long have they persisted?*

Have there been any recent significant life changes or events?*

Yes

No

If you selected Yes, please describe below:*

Mental Health History

Have you previously received counseling, therapy, or other mental health services?*

Yes

No

If you selected Yes, with whom and when?*

Have you previously received any mental health diagnoses?*

Yes

No

If you selected Yes, please specify.*

Are you currently taking any psychiatric medications?*

Yes

No

If you selected Yes, please specify the name, dosage, and how long it has been prescribed to you.*

Please check all that apply:

Anxiety*

Current

Past History

Never

Depression*

Current

Past History

Never

Stress*

Current

Past History

Never

ADHD*

Current

Past History

Never

School Concerns (Behavioral, Social, Emotional, Academic, Etc.)*

Current

Past History

Never

Work Concerns (Career Direction, Peer Conflict, Burnout, Etc.)*

Current

Past History

Never

Family Conflict*

Current

Past History

Never

Relationship Conflict*

Current

Past History

Never

Anger Concerns*

Current

Past History

Never

Financial Concerns*

Current

Past History

Never

Eating Concerns*

Current

Past History

Never

Sleeping Concerns*

Current

Past History

Never

Little to No Motivation*

Current

Past History

Never

" I Have No Idea How to Adult"*

Current

Past History

Never

Grief/Loss*

Current

Past History

Never

Hopelessness*

Current

Past History

Never

Loneliness*

Current

Past History

Never

Trauma*

Current

Past History

Never

Physical/Medical Health Concerns*

Current

Past History

Never

Substance Misuse*

Current

Past History

Never

Thoughts of Self-Harm*

Current

Past History

Never

Thoughts of Suicide*

Current

Past History

Never

Thoughts of Harming Others*

Current

Past History

Never

Other

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