Psychosocial Assessment

Client Name: Date/Time:

Acculturation/Assimilation
What made you decide to come to the US? Tell me about your journey to the US:

What was the resettlement experience like for you?

What were you hopes in coming to the US?

Client Concerns
*Rank 0-10, 0 being of lowest concern to 10 being of highest concern Client Problems (quote client words if possible): Name the problems you have right now (Explore): 1. 2. 3. 4. 5. Client Worries (quote client words is possible): What are the three things you worry about most (Explore)? 1. 2. 3. Do you experience any feelings or emotions as a result of the situation you are in? Yes No Incongruent What are some of the feelings and emotions you are experiencing? List as many as the client names (Explore): 1. 2. 3. 4. 5. Rank 0-10*

Rank 0-10*

Rank 0-10*

Assessments/Goals
Hopkins Symptoms Checklist Completed Asian Values Scale-Revised Completed Goals/Needs Form Completed

Human/Social Capitol
Number of close relative individual has in the US, on their side of the family. _____________________________________ Assessment of Family/Friends in US (who?):
Relatives/Friends in US Check if none in the US Living with individual 1-2 hours away Within a days travel Farther, but live in US Can stay with (in an
emergency situation)

Individuals Parents Siblings Relatives Friends Community /church members

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Others (who?) Who lives in the house with you? (Name/Relation): Do you rent the house? Yes No Unknown If yes, whos name is it in: ____________________________________________ Do you own the house? Yes No Unknown If yes, whos name is it in: _____________________________________________ How often does individual visit back How much can individual rely on relatives How much can you rely on relatives and very and forth with family or extended and very close friends for financial help? close friends for emotional help and family? Certain can get help when need sympathy if you have problems? Daily or nearly daily Probably can get help when need Certain can get help when need 1x a week Not sure Probably can get help when need 1x a month Probably cannot get help if need Not sure a few times a year Cannot get help if need Probably cannot get help if need Less than 1x a year Cannot get help if need Assessment of individuals time within their ethnic and/or mainstream communities (check): All/almost More About half More All/almost all For all ethnic Ethnic and half Mainstream Mainstream Leisure time (fun, recreation, socializing w/both men and women) Network of women friends Help/support (Not financial) in times of need Financial help to put resources together to improve life. Education for self and children Restaurants/grocery/stores Religion/spirituality Work or as a place to look for work Childcare/persons help raise your children A place to live/housing If you decided to leave your husband, how much would it affect the time you spend in your ethnic community? No effect Would spend more time in ethnic community Would spend less time in ethnic community How does individual get around? Public transportation Yes No Other: ___________________________________________________________ Has license Yes No Depend on husband to drive around Yes No Allowed to go places without husband: Yes No Why? _________________________________________________________________ Does client have the means to transport themselves? Yes No Why? _________________________________________________

Financial Assessment
Do you work? Yes No Does your Partner work? Yes No Unknown Summary of INDIVIDUALS sources of Income: *Indicate dollar amounts, monthly, yearly, other *Indicate if unknown Source Amount Full time employment (include informal work) Part time employment (include informal work) Unemployment benefits VA benefits Child support Alimony Family/Friends TAFDC Food Stamps Emergency Assistance SSDI
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SSI Other: Summary of PARTNERS sources of Income: *Indicate dollar amounts, monthly, yearly, other *Indicate if unknown Source Amount Full time employment (include informal work) Part time employment (include informal work) Unemployment benefits VA benefits Child support Alimony Family/Friends TAFDC Food Stamps Emergency Assistance SSDI SSI Other: How much of your earnings are How much of your partners Do you have access to money when you need it or do you directly under your own control earnings do they turn over to have to ask your partner? FOR: (to use as you please)? you to handle (to use as you Basic needs, food, clothing: All Mostly Partly please)? Always/almost always have access Little None All Mostly Partly Usually have access Usually have to ask Little None Almost/almost always have to ask Leisure activities or extras for yourself: What is the highest status job the individual held in their country?: ________________________________________________________ Always/almost always have access ________________________________________________________ Usually have access Usually have to ask ________________________________________________________ Almost/almost always have to ask Major purchases (TV, appliances, car, etc): What is the highest status job the individual held in the US?: ________________________________________________________ Always/almost always have access ________________________________________________________ Usually have access Usually have to ask ________________________________________________________ Almost/almost always have to ask

Educational Assessment
Individuals level of education completed in their country: Education Check None Less than high school High school
2 Year College/Vocational Training- NO degree 2 Year College/Vocational Training degree/certificate

Individuals level of education completed in the US: Education Check None Less than high school High school
2 Year College/Vocational Training- NO degree 2 Year College/Vocational Training degree/certificate

4 Year college NO degree 4 Year College - degree Graduate College - NO degree Graduate College - degree Other:

4 Year college NO degree 4 Year College - degree Graduate College - NO degree Graduate College - degree Other:

Did the individual work in their country? Yes No Did the individuals work in their country prepare them for work in the US? Yes No N/A Did the individuals education obtained in their county prepare them for work in the US? Yes No N/A Did the individuals education obtained in the US prepare them for work in the US? Yes No N/A Does the individual want to continue their education or technical training in the US? Yes No Unsure Describe:
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____________________________________________________________________________________________________________ What challenges are the individual facing while trying to obtain work/education? _______________________________________ ____________________________________________________________________________________________________________ Partners level of education completed in their country: Partners level of education completed in the US: Education: Check Education: Check None None Less than high school Less than high school High school High school
2 Year College/Vocational Training- NO degree 2 Year College/Vocational Training degree/certificate 2 Year College/Vocational Training- NO degree 2 Year College/Vocational Training degree/certificate

4 Year college NO degree 4 Year College - degree Graduate College - NO degree Graduate College - degree Other:

4 Year college NO degree 4 Year College - degree Graduate College - NO degree Graduate College - degree Other:

Did their Partner work in their country? Yes No Unknown Did this work prepare their Partner for work in the US? Yes No Unknown Did their Partners education obtained in their county prepare them for work in the US? Yes No Unknown Did their Partners education obtained in the US prepare them for work in the US? Yes No Unknown

Housing Assessment
Does the individual need/want housing: Yes No If yes, describe: _______________________ _____________________________________ _____________________________________ What kind of assistance would the individual like? Check all that apply: None Shelter applying for public/subsidized housing Landlord advocacy Eviction prevention/intervention Utility assistance Home buyer education relocation support Landlord/tenant education rent/mortgage arrearages Other:

Medical/Mental Health Assessment

Has the individual or family member(s) received any medical treatment because of the violence? Yes No If Yes, describe: _______________________________________________________ _______________________________________________________ Has the individual or family member(s) received any mental health services as a result of the violence? Yes No If Yes, describe: __________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ Does the individual have any Medical concerns for themselves or Does the individual have any Mental Health concerns for their family? themselves or their family?: Yes No If Yes, describe: _______________________________ Yes No If Yes, describe: ___________________________ _______________________________________________________ ___________________________________________________ Have you been a victim of community violence/War?: Yes No Have your children been victims of community violence/war? If yes, describe: _________________________________________ Yes No If Yes, describe: __________________________ _______________________________________________________ ___________________________________________________ _______________________________________________________ ___________________________________________________ As child did you experience any abuse or trauma?: Yes No Undisclosed Check all that apply: Physical abuse Verbal/Emotional Abuse Neglect Sexual Abuse/Molestation Military Trauma Witness Domestic Violence/Abuse Witness Substance Abuse of household members Other: ___________________________________________________________________________________________________ Did either of your parents have Emotional or Physical difficulties?: Yes No If yes, describe: __________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________

Legal Assessment
Type Police Probate Court Individual Perpetrator Describe:

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Criminal Court DCF/DSS Other: _______________ Reports attached Yes No Describe: Does the individual currently need help with legal issues?: Yes No Unsure If yes: TRO/RO Divorce Child Support Visitation Immigration Criminal Other _____________________________________________________________________________________________________ Describe needs: ______________________________________________________________________________________________ ____________________________________________________________________________________________________________ Individuals Strengths/Abilities/Resiliency (Protective factors, skills, talents, interests, goals) Personal Qualities: Daily Living Situation: Employment: Education: Financial: Legal: Social Supports: Health: Leisure/Recreational: Spirituality/Culture/Religion:

Staff Name: Supervisor Name:

Staff Signature Supervisor Signature:

Date: Date:

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