Psycho Social Assessment Documentary History • Headings are in BOLD and should always be in your document
• Instruction for content required in Italic
• Be sure to remove italic instruction before completing Assessment notation/documentation

• All content is about the client, never about you the counsellor
PSYCH-SOCIAL ASSESSMENT
NAME: (CLIENT)
ADDRESS:
PHONE:
REFERRAL ROUTE:
PRESENTING PROBLEM: (s)/issue(s)/ situation(s)
APPEARANCE AND BEHAVIOUR.
Physical/behavioral observations: physical appearance, grooming,
Mood, unusual habits.
HISTORY: include date of onset, people involved, precipitating and important events that led to presenting situation and client’s attempts to resolve problems
Indicate life areas of impact of presenting problem: concentration, interpersonal, quality of life, safety, other
Previous counselling: date and reason
Recent or ongoing problem: medical, financial, legal
Strengths, resources, support system, family, spouse/partner, friends, colleagues, supervisor. Coping skills, lifestyle .community, work environment, spirituality, leisure activities, other
Substance use screening: alcohol, Drugs, medication, caffeine, Nicotine: per day/per week/per month

Psycho Social Assessment Documentary History Risk assessment

Risk of suicide: ideation, intent, plan, previous attempt
Risk of self-harm/injury: ideation, plan, intent, previous attempt
Risk of harm to/from others: threats, intent, plan, previous attempt
(Specify) addiction, child abuse, childhood abuse
Spouse abuse, family history of suicide/violence
Previous suicide attempts, impaired judgment
Lack of social support, recent loss
self-injury,) previous mental health/ suicide hospitalization
GOALS: Specify and SMART goal content
(Specific, measurable indicators, achievable, realistic and timely)
Worker attempting:
1 Main Goal (big picture goal for client)
5 domains present = 1 sub goal for each domain.
3 Action goal for each domain focused sub goal
Can use actual goal tree prepared with client during assessment goal setting work
*Workers Signature and credentials
(Print name and credentials under signature)
DATE: (document completed)
* Your report should be written as a first interview (psychosocial history/assessment) sessional report with yourself projected into the role as counselor. * Headings to be used for report writing in Bold. With Exception of Demographics: Use narrative (full sentences) for all areas documented under headings.
This is the cline Lizzy came into the country as a refugee and was pregnant as at the time. Since, it’s been a struggle for her to settle down in the country. The recent on-going problem with this client now is both financial and legal. Financial, because she does not have a stable job, with her only child, it’s been hard taking care of her and, she trying to work on her stay in the country.

Psycho Social Assessment Documentary History and the Case Study

Lizzy was the third child in her family, raised by a single parent, studied back in her home town in the southern part of Nigeria and the level of education she has from back home is not useful, because of her status in the country Canada, parent was divorced when she was young. She also got pregnant while leaving the country and was able to give birth to the child here, and the distance between her and her boyfriend led to their separation and she has no family member here.
Lizzy is suffering from anxiety disorder and fear, as the housing accommodation she could afford for herself and her daughter is not in a great environment where she wants her daughter to grow in, also, this apartment building is suffering from bed bugs, which gets her scared every night and leads to her not sleeping at night. Lizzy is still finding it hard to get use to the culture here, considering it is different from where she came from. Lizzy finds it hard to get her kind of job which is customer service job as it is necessary to have a Canadian experience and even with the agency jobs she got, she find it hard to do a longer shift because of her daughter because she does not have anyone she could stay with and cannot afford to pay someone to watch her. Lizzy also complains about how she is been treated at the work place and she thinks people are treating her in such manner because of her race, and the way she speaks (accent). According to Lizzy, her religion/spirituality has always been helping her to deal with her fears and helping her to stay positive. Lizzy finds it so hard to talk to anyone about the situation she is going through, because of everything she is going through that has lowered her self-esteem in a way and seems not to be able to confide in any one. Also, she thinks because of her accent she will not be able to find anyone that would want to be her friend. Often times, when Lizzy talks, she says she wished she had her family here or even have a husband, but she is having to accept what she is going through and hope for the best. She is sad, because she has no one to share her thoughts with and no one could help her in any way as the people she left back home her expecting money from her. Lizzy is also concern about her daughter betty, she is seeming to have difficulty helping her grow, she is concern, betty would not turn out as she did, even though she might be able to fix what has happened between her and betty’s father, she is scared she might not be able to give betty the best. Her support system is welfare until she can get a job that could support her and her daughter no family, no spouse to support. Also, while she is trying to get a job, she also volunteers to helping in her church. Lizzy’s home condition is not completely great, because of the bug disturbance, as most times they are asked to evacuate the building, so the place could be spray, this has also been a source of stress for her.
The education Lizzy has from her country Nigeria is a diploma in communication, which she did not get to finish, before she had the opportunity to leave the country. Lizzy has not been able to go back to school since she has been here, and she is hoping to go as soon as daughter has grown up to a certain age like 11, when she is old enough to take care of herself. The kind of employment she has had since she came in was employment through some agencies, which most times are contract work if not, she keeps getting laid off.
The grief issued she has is not having to end her relationship with her man, because of the distance between them. Lizzy thinks the way grew up was what affected her to this point in her life, she believes the way she was raised by a single parent did not help her unlike if she was raised by both her parents and she is now concern about her daughter’s well-being, as she does not want her to grow up like she did or even end up like she did too. The support system she has right now is the welfare she is getting, which is temporary, and maybe a little help from the volunteering work she is doing at her church. Al a so, the environment she lives in, she thinks it is a threat to her and her daughter’s life.
Lizzy does not use any substance at all, however Lizzy thinks she might be either harm to herself or her daughter because, she is really stressed out and not thinking straight which can lead to her developing mental illness and might lead to her having difficulty raising her daughter properly.