Psychosocial Assessment Intake Interview John Doe Form

1
Psychosocial Assessment Intake Interview Form
DEMOGRAPHIC INFORMATION
Name: ___John Doe_____________ Date: ____7/10/2021________________
Address: ___123 _Knight-Riddler Rd. Date of Birth: __9/8/1989____________
___Setting Sun MD._________ Age: _______31 years old___________
Phone Number: _302 459 XXXX_______ Insurance information: Blue Cross of MD

 Insured ✔
 Uninsured
Referred by: Dr. Tony Stark PCP: Dr. Tony Stark
 Releases signed Psychiatrist:
 Consent to Treatment signed
Diagnosis: Major Depressive Disorder Dominate Hand: R / L

single episode, moderate (F32.1)
Obstructive Sleep Apnea Hypopnea (G47.33) Marital status: Single
Z63. 0: Relationship distress with spouse or partner.
Z81.8 (family history of other mental and behavioral disorders)
Z56.9 Other Problem related to Employment.
Z60.0 Phase of Life problem
PRESENTING PROBLEM
Chief complaint: For the past three weeks John has been experiencing symptoms of
immense sadness, hopelessness, and depressed moods. John has socially withdrawn from
his friends or family and no longer finds enjoyment in the activities that he used to love.
John has also recently missed the past two days of work. John reports that he has been
having trouble sleeping at night as well.
2
Mood (self-reported): Tired, Sad, and Lonely

Affect (observed by clinician): Seems unfocused and unmotivated. Self-maintenance
lacking (messy hair).
Current symptoms:
 Anxious
 Appetite changes (not hungry
anymore)
 Concentration difficulty
 Indecisiveness
 Racing Thoughts
 Delusions
 Depressed mood (sometimes)
 Difficulty sleeping (nightly)
 Hx of Eating disorder
 Fatigue (every day)
 Fears
 Feelings of guilt/ worthlessness
 Hopeless
 Flashbacks/Dreams
 Hallucinations (not anymore)
 Social Withdrawal
 Homicidal thoughts
 Impulsivity
 Compulsivity
 Irritability/Anger outbursts
 Loss of interest or pleasure
 Manic symptoms
 Memory loss
 Motivation difficulty
 Pain
 Panic attacks
 Restlessness/psychomotor
agitations or psychomotor
retardation
 Suicidal thoughts
 Weight gain
# Time Frame 3 weeks
Life Stressor Notes: Three weeks ago, John’s longtime girlfriend of 6 years (Jane Weber) broke
up with him and moved to Louisiana. John knew that Jane was moving and the coupled had
decided to try a long-distance relationship for a few months; however, the day before Jane was
supposed to leave, she ended the relationship. She said that she was unhappy with John and that
he doesn’t care for anyone but himself. Unknown to Jane, John had plans to propose to her once
he found a new job in Louisiana. Prior to the incident, John was receiving a lot of pressure from
his church to settle down and get married already. John feels depressed that he lost his girlfriend
and says that he has not been the same since the breakup. John states that he feels like he is not
where he should be at this stage of his life.
Patient’s Long-Term Goals:

“Feel better again.”
“Travel to Spain, getting married, having kids, and buying a dog.”
________________________________________________________________________
Patient’s Short-Term Goals:
“Getting good sleep”
“Wake up and do the “little things again” (shower, get dressed go to work) again
“Get back to doing healthy hobbies such as Brazilian Jiu-Jitsu, building model tank
crafts, carpentry, and cooking.”
________________________________________________________________________
Patient’s Strengths (3):

John has steady employment. He is financially stable since he recently finished paying
off his student loans. He has residential stability and owns his own home.
Support System:
Family, friends, teammates, church community.
________________________________________________________________________
MENTAL HEALTH HISTORY
Previous mental health treatment (Psychiatrist, Psychologist, counselor, inpatient

hospitalization): N/A
Counselor: N/A
MEDICAL HISTORY:
Developmental history (pregnancy, delivery, developmental milestones):

Nuchal cord in utero but removed by doctor before delivery.
Developmental milestones such as verbal skills, motor skills, and social skills were met
during age-appropriate times.
________________________________________________________________________
Current medical conditions:

Sleep Apnea
Uses a continuous positive Airway Pressure machine (CPAP machine) to deliver air
through the upper airway. He says it helps him sleep at night.
___________________________________________________________________
Past medical issues (childhood diseases, remissions, surgeries, etc.):

Wisdom teeth removal and hernia repair surgery.
________________________________________________________________________
Allergies:
Pollen, dust mites, mold, and bee stings
History of family illnesses:

Moms side- High blood pressure, breast cancer, colon cancer, and anxiety
Dads side- Diabetes and depression
________________________________________________________________________
Current medications (including OTC and herbal remedies):
Multivitamin, Omega 3 fish oil, Hibiscus tea, Fiber capsules
________________________________________________________________________
SOCIAL HISTORY:
Relationships with parents:

John is incredibly close with his parents (Bob age 64 and Sue age 58). He calls home
every day and sees his parents every few days. They always call John when there is an
issue or when something needs to be fixed.
_____________________________________________________________________________
Relationships with siblings:

John is the oldest of four. Bobby (age 20) Sally (age 22), Suzie (age 25), Amy (age 29).
John is very close to his siblings. John loves all his siblings the same but gets along best
with Amy. John considers himself to be a role model to Bobby and Sally.
______________________________________________________________________________
Abuse history:
No history of abuse (victim or perpetrator)
_____________________________________________________________________________
School performance:
In high school, John graduated with mostly C’s and some B’s. However, in college John
graduated at the top of his class with an accumulated 3.87 GPA.
____________________________________________________________
Highest level of education:

Bachelor’s degree in Business Administration
__________________________________________
Regular classes or special needs:

Regular courses no history of educational accommodations
Marital/Significant relationship history:

No previous marriages. Dated a few girls in his early 20s but nothing long term. His
longest and most serious relationship was with Jane.
______________________________________________________________________________
Current status and family relationships (number of years married, spouse, children, etc.):
Single, no children. Deeply connected to the church and would attend every Sunday.
Feels like he should be married with kids by now and is sad about the breakup.
Sexually Active (age of onset): _Virgin, no prior sexual experinces ______________________

 Monogamous (Yes, while dating. But with no sexual activity. John has strong religious
beliefs about waiting to be married before engaging in sexual acts).
 multiple partners No
 same sex (include experimentation) No
 Disease Protection use: _____N/A_____________________________________
 Birth Control use: _____N/A_______________________________________________
 Dysfunction _____N/A_______________________________________________
 Rate Level of Satisfaction (physical enjoyment, emotional satisfaction, &frequency) :
N/A
EMPLOYMENT HISTORY:
Current employment:
Business Administration Specialist at Salient CRGT INC.
______________________________________________________________________________
Work history:
Worked at Applebee’s as a waiter for 5 years.
Became the Applebee’s assistant manager for three years.
Interned at Nava as an undergraduate
Worked at Nava for two years
______________________________________________________________________________
LEGAL HISTORY:
Current legal involvement:

No current criminal record or allegations.
______________________________________________________________________________
Past legal involvement:

No criminal history or previous arrests.
______________________________________________________________________________
MILITARY HISTORY:
Past or current military involvement: N/A
______________________________________________________________________________
SUBSTANCE USE/ABUSE HISTORY:
Alcohol use history (age of onset, amount, frequency, duration, problematic, etc.):
John only drinks on special occasions with friends or during family gatherings. He does
not drink excessively but instead only drinks to get buzzed during parties. He started
drinking at the legal age of 21.
______________________________________________________________________________
Family History of Alcohol use (age of onset, amount, frequency, duration, problematic, etc.):
No history of alcohol use in his immediate family.
However, John’s uncle on his father side drink excessively.
______________________________________________________________________________
Substance use history (age of onset, amount, frequency, duration, problematic, etc.)
No personal history of substance use.
______________________________________________________________________________
Family History of Substance use (age of onset, amount, frequency, duration, problematic, etc.)
No history of substance abuse immediate or extended family
______________________________________________________________________________
Nicotine use: None
Caffeine use:
Daily throughout the day and before bed. Coffee, 5-hour energy, expresso, monster, coke.
Problematic Behaviors (age of onset, amount, frequency, duration, problematic, etc.):

No history of problematic behaviors
______________________________________________________________________________
Other: N/A
______________________________________________________________________________
Physical Appearance: Hair Blonde Height 5’ 11”

Weight 150 lbs. Body Type Muscular Build
Other large burn mark on lower arm
Motor Activity: Walking Excellent Standing Excellent
Sitting Excellent Range of Motion Excellent
Other__N/A___________

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Psychosocial Assessment Intake Interview Form

Phone Number: _302 459 XXXX_______ Insurance information: Blue Cross of MD

Diagnosis: Major Depressive Disorder Dominate Hand: R / L

Mood (self-reported): Tired, Sad, and Lonely

Patient’s Long-Term Goals:

Patient’s Strengths (3):

MENTAL HEALTH HISTORY

Previous mental health treatment (Psychiatrist, Psychologist, counselor, inpatient

Developmental history (pregnancy, delivery, developmental milestones):

Current medical conditions:

Past medical issues (childhood diseases, remissions, surgeries, etc.):

History of family illnesses:

Relationships with parents:

Relationships with siblings:

Highest level of education:

Regular classes or special needs:

Marital/Significant relationship history:

Sexually Active (age of onset): _Virgin, no prior sexual experinces ______________________

Current legal involvement:

Past legal involvement:

SUBSTANCE USE/ABUSE HISTORY:

Nicotine use: None

Problematic Behaviors (age of onset, amount, frequency, duration, problematic, etc.):

Physical Appearance: Hair Blonde Height 5’ 11”

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