Tranquility Counseling
Patient Name: _______________________________  MR# ________________

Tranquility Counseling
PSYCHOSOCIAL ASSESSMENT

ADMISSION DATE
ASSESSMENT DATE
INFORMATION PROVIDED BY:
Patient
Other
DATE OF BIRTH:
SEX:
MARITAL STATUS:
1.        PRESENTING PROBLEMS / PRECIPITATING EVENTS:

PRESENTING PROBLEM / HISTORY OF PRESENTING PROBLEM:         (Chief complaint and presenting problem, including recent events and history leading to admission into treatment)















2.        FAMILY HISTORY:

FAMILY OF ORIGIN HISTORY (Including siblings and relationship history to present with family of origin)











HOW HAS YOUR SUBSTANCE ABUSE/PSYCHIATRIC PROBLEMS AFFECTED YOUR FAMILY OF ORIGIN?FAMILY OF ORIGIN HISTORY OF SUBSTANCE ABUSE AND/OR MENTAL ILLNESS:                    DENIES










FAMILY HISTORY OF MEDICAL ILLNESS:

SPIRITUAL OR RELIGIOUS HISTORY/ASSESSMENT (CLINICAL IMPRESSIONS-):
RELIGIOUS BACKGROUND / CURRENT LEVEL OF ACTIVITY, INCLUDING UPBRINGING AND VALUES WITHIN FAMILY OF ORIGIN, CHOICE AND HOW IT MIGHT HAVE AFFECTED IDENTITY








CURRENT SPIRITUAL BELIEFS AND PRACTICES:         (Including belief in higher power / spirit)







DO YOU MEDITATE?          YES                  NO


HAS YOUR SUBSTANCE ABUSE/MENTAL ILLNESS AFFECTED SPIRITUAL/RELIGIOUS ASPECTS OF LIFE?  IF YES, EXPLAIN HOW.           DENIES
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