Psychosocial Assessment
A psychosocial assessment template that guides clinicians through intake: presenting concern, mental health and medical history, substance use, social context, strengths, risk overview, and initial impressions.
How to use this template
A psychosocial assessment builds the story behind the referral: what is happening, in what body, in what life. The goal is a working formulation, not a completed form. Use these sections as a map rather than a script. Follow the patient's thread, keep their own words where you can, and circle back to headings you missed before the end. A skipped section is worth one line explaining why it was deferred.
Identifying information and referral
Capture the basics in a line or two: age, pronouns, living situation, occupation or school, and how they came to you.
Presenting concern
What brings them in now, in their own words? Note onset, course, and anything that makes it better or worse, plus what they have already tried. End with what they want from treatment; the answer is often more specific than the referral suggests.
Mental health, medical, and family history
Cover prior mental health care: diagnoses, therapy, medications tried and their effects, and any hospitalizations. Add current medical conditions, medications, sleep, pain, and recent changes. Close with family history of mental health and substance use concerns, which often reframes the presenting picture.
Substance use: what was covered
Check what you asked about. For anything significant, capture pattern, amount, longest period without, and impact on work, relationships, or health in the summary.
Social context and daily life
Sketch the life this person actually lives: housing and who is home, relationships, work or school, money pressures, legal issues, culture and faith, and what an ordinary day looks like from waking to sleep. Daily structure is often where treatment succeeds or stalls.
Strengths and supports
Formulations lean negative by default. Check what this person has going for them; the plan will be built on these.
Risk overview
Screen according to your setting's protocol and document plainly: current safety concerns, history of suicidal thinking or self-harm, risk of harm to others, abuse or neglect concerns including mandated reporting duties, intimate partner violence, and access to lethal means. Record what was asked, what was reported, and what actions you took.
Initial impressions and plan
Draft the working formulation: the presenting picture, what seems to drive and maintain it, the strengths that can carry the work, provisional diagnostic impressions, and recommended next steps, including referrals and what you will revisit next session.
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