Psychosocial History Questionnaire Form
Please complete this questionnaire to provide a brief overview of your psychosocial history. This form is for general intake purposes only.
Full Name
*
First Name
Last Name
Age
*
Current Living Situation
*
Living alone
With family
With roommates
Other
Who do you consider part of your support system?
Family
Friends
Coworkers/Classmates
Community/Religious Groups
No one
Other
Employment or School Status
*
Please Select
Employed full-time
Employed part-time
Unemployed
Student
Retired
Other
What are your current major sources of stress?
How do you typically cope with stress?
Do you currently use any substances (e.g., alcohol, tobacco, recreational drugs)?
No
Yes
Prefer not to say
Have you previously received counseling or support services?
No
Yes
Additional notes or anything else you would like to share
Submit
Should be Empty: