1 COU 680 Adult Psychosocial Assessment Sabrina Date of appointment: Today Time of appointment: 5:00 pm Client Name: Sabrina Hinajosa Age: 29 DOB: 3/23/89 Gender:  Male  Female  Transgender Preferred Name/Nickname: N/A Ethnicity:  Hispanic  Non‐Hispanic Race: Caucasian Current Marital/Relationship Status:  Single  Married  Divorced  Widowed  Domestic Partnership Name of Person completing form: Sabrina Relationship to client: Self PRESENTING PROBLEM (Briefly describe the issues/problems which led to your decision to seek therapy services): I recently lost my mother-in-law to a sudden heart attack immediately prior to the recent hurricane. Within a matter of a single day I lost the mother figure in my life, was evacuated from my home, and had a hurricane destroy parts of my house. I’m completely overwhelmed, sad, and angry at the world. How severe, on a scale of 1‐10 (with 1 being the most severe), do you rate your presenting problems? MOST SEVERE 1 2 3 4 5 6 7 8 9 10 LEAST SEVERE PRESENTING PROBLEM CATEGORIZATION: (Please check all the apply and circle the description of symptom) Symptoms causing concern, distress or impairment:  Change in sleep patterns (please circle): sleeping more sleeping less difficulty falling asleep difficulty staying asleep difficulty waking up difficulty staying awake  Concentration: Decreased concentration Increased or excessive concentration  Change in appetite: Increased appetite Decreased appetite  Increased Anxiety (describe): I have a lot of fear of the unknown. Everything feels out of my control.  Mood Swings (describe): I’m irritable all of the time. I go back and forth between extreme bouts of sadness and complete anger and rage at the situation. The only place I feel calm is with my kids and only because I really focus on making sure they are ok.  Behavioral Problems/Changes (describe): I struggle to stay focused on anything other than taking care of my kids. I feel aimless and purposeless and have stopped putting forth much effort at work or in our home. Everything just seems both overwhelming and pointless.  Victimization (please circle): Physical abuse Sexual abuse Elder abuse Adult molested as child Robbery victim Assault victim Dating violence Domestic Violence Human trafficking DUI/DWI crash Survivors of homicide victims Other: 2 Other (Please describe other concerns): How long has this problem been causing you distress? (please circle) One week One month 1 – 6 Months 6 Months – 1 Year Longer than one year How do you rate your current level of coping on a scale of 1 – 10 (with 1 being unable to cope)? UNABLE TO COPE 1 2 3 4 5 6 7 8 9 10 ABLE TO COPE EMPLOYMENT: Currently Employed?  Yes  No If employed, what is your occupation? Bank teller Where are you working? XYZ Bank How long? 3 Days/Months/Years Do you enjoy your current job?  Yes  No What do you like/ ...

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COU 680 Adult Psychosocial Assessment Sabrina
Date of appointment: Today Time of appointment: 5:00 pm
Client Name: Sabrina Hinajosa Age: 29 DOB: 3/23/89
Name/Nickname: N/A
‐ Hispanic Race: Caucasian
Name of Person completing form: Sabrina Relationship to
client: Self
PRESENTING PROBLEM (Briefly describe the issues/problems
which led to your decision to seek therapy services):
I recently lost my mother-in-law to a sudden heart attack
immediately prior to the recent hurricane. Within a matter
of a single day I lost the mother figure in my life, was
evacuated from my home, and had a hurricane destroy parts
of my house. I’m completely overwhelmed, sad, and angry at
the world.

2. How severe, on a scale of 1‐ 10 (with 1 being the most severe),
do you rate your presenting problems?
MOST SEVERE 1 2 3 4 5 6 7 8 9 10 LEAST SEVERE
PRESENTING PROBLEM CATEGORIZATION: (Please check
all the apply and circle the description of symptom)
Symptoms causing concern, distress or impairment:
sleeping less difficulty falling asleep
difficulty staying asleep difficulty waking up difficulty staying
awake
excessive concentration
unknown. Everything feels out of my control.
back and forth between extreme bouts of sadness
and complete anger and rage at the situation. The only place I
feel calm is with my kids
and only because I really focus on making sure they are ok.
focused on anything other than taking care of

3. my kids. I feel aimless and purposeless and have stopped
putting forth much effort at work or in our home.
Everything just seems both overwhelming and pointless.
Elder abuse Adult molested as child
Robbery victim Assault victim Dating violence Domestic
Violence
Human trafficking DUI/DWI crash Survivors of homicide
victims
Other:
2
Other (Please describe other concerns):
How long has this problem been causing you distress? (please
circle)
One week One month 1 – 6 Months 6 Months – 1 Year Longer
than one year
How do you rate your current level of coping on a scale of 1 –
10 (with 1 being unable to cope)?

4. UNABLE TO COPE 1 2 3 4 5 6 7 8 9 10 ABLE TO COPE
EMPLOYMENT:
Currently Emplo
occupation? Bank teller
Where are you working? XYZ Bank
How long? 3 Days/Months/Years
like/dislike about your job? I used to really
like my job. I really like the people I work with and it offers a
lot of good interaction with people in the nearby
community. I’m typically a really outgoing person that people
like, so this has been a good fit for me. Right now
though, I don’t really get anything out of it other than knowing
I need the job because we need the money. It’s
like I go in and do what I have to do until I leave. My focus has
been lacking and it is showing.
If you are not currently employed, how long has it been since
you last worked? Months/Years
What was your occupation before becoming unemployed?
What led to becoming un‐ employed?

5. PSYCHIATRIC/PSYCHOLOGICAL HISTORY:
If yes, name of current psychiatrist Length of Treatment
Have you ever been diagnosed with a mental health, emotional
or psychological condition?
If yes, what diagnosis were you given? Post-Traumatic Stress
Disorder
When? 5 years ago
By Whom? Dr. Mental Health
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Previous counseling/hospitalizations for mental health/drug and
alcohol concerns
Dates of Service
Place/Provider

6. Reason for treatment
Were the services helpful?
January 2013-August
2013
JKL Counseling and
Wellness Center
Rape Trauma Yes
SAFETY CONCERNS:
when and how? Well, I didn’t fully attempt. I
had plans to jump off the bridge near my house, but ultimately
changed my mind.
Is there a history of suicide in your immediate and/or extended
when I was 13 years old.

7. explain
Additional Information: (please add additional information as
needed to address past and current safety issues): I’m
not actively suicidal, but I am aware that my last experience got
me really close. I don’t feel as out of control right now
as I did then, but I have some small fear that those feelings of
chaos and rage are resurfacing and I won’t be able to
control them on my own.
4
FAMILY MENTAL HEALTH HISTORY
Please identify if any members of your family have had a
history of any of the following mental health/drug
abuse/legal concerns.

8. Family History
Depression
Anxiety
Bipolar
Disorder
Schizophrenia
ADHD/ADD
Trauma
History
Abusive
Behavior
Alcohol
Abuse
Drug
Abuse

9. Incarceration
Self X X
Mother X X X X
Father X X X
Sister
Brother
Maternal
Uncle
X X X X
Paternal
Uncle
X
Maternal
Aunt
X
Paternal
Aunt
Maternal
Grandmother
X X

10. Paternal
Grandmother
Maternal
Grandfather
X
Paternal
Grandfather
X X
Biological
Child
X
RELATIONSHIP/MARITAL STATUS
‐ Significant Other (Not Living Together)
If applicable, list divorces and separations:
What do you think is important for us to know about your
significant relationships – current & past? My parents

11. divorced when I was about 3 years old and I lived largely with
my mom although I saw my dad every couple of weeks.
My dad was always “fun” but really irresponsible. I remember
that even as a kid. He got in trouble a lot and spent some
time in jail for stealing a car. He just didn’t seem to ever take
responsibility for anything. His bipolar disorder only
complicated that experience. He went from the highest of highs
to the lowest of lows and ultimately ended up shooting
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himself one night, alone in his apartment. My mom was a bit of
a “hippie”. She came from a highly abusive and
controlling family, so she decided to take the opposite approach
with me. She was, on occasion, physically abusive to
me, but mostly she just moved in and out of the world high on
drugs and full of “free love”. I lived a nomadic existence
with her and I often felt like the parent to my parents. I met my
husband Tony in high school. We started dating and I
immediately fell in love with him and his family. They
welcomed me in for meals and made life feel “stable”. His
mom, Maria, was like the mom I always wanted, and she often
said I was the daughter she wished she had. We were
very close, and I loved her very much. I have two daughters of

12. my own (6 and 8), and they are the center of my
universe.
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FAMILY COMPOSITION
Spouse/Significant Other’s Name: Tony Hinajosa Age: 30
employment:
BIG House Construction
Occupation: General Contractor
Please list the names, ages, relationships and other relevant
information regarding all immediate family members
whether living in‐ or outside the home. Please include all
members currently residing in YOUR household.
Name
Gender

13. Age
Relationship To
Client
Living With Client
Tony Hinajosa Male 30 Spouse Yes
Lyla Hinajosa Female 8 Child Yes
Amelia Hinajosa Female 6 Child Yes
Henry Hinajosa Male 58 Father-in-law No
Meg Wick Female 56 Mother No
What else do you feel/believe would be helpful, or important for
us to know/understand about your
relationships with your family or about your family members?
I don’t have regular contact with my mom. She lives about three
hours away and we only really see each other around
Christmas and out of a sense of obligation—mostly for my kids.
She doesn’t really put in any effort and I don’t either.
RECENT LOSSES:

14. Who? Mother-in-law When? 1-month ago Nature of Loss? Heart
attack
Other Losses: father—suicide when I was 13; all my
grandparents are also deceased
HOUSING:
Do you currently:
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How long have you lived in your current living situation? 6
years
How often have you moved in the past two years? N/A
What else do you think is important for us to understand about
your housing/living situation?
We currently live at home but our house was flooded with the
hurricane, so it needs pretty extensive repair.

15. Typically, we would stay with my in-laws, but with my mother-
in-law’s death there have been a lot of family visiting,
and we don’t want to overburden Henry. I also don’t think I
could handle being there without her. Just the thought of
that house makes me cry. Really any reminder of her does, but
that is particularly hard for me. Our home is functional,
but we are without carpet and the paint is peeling off. My
husband is in construction, so I know we will get it fixed
eventually, but it is chaotic and we don’t have the insurance
money to pay for anything right now.
FOSTER CARE INVOLVEMENT
‐ Familial Placement
HEALTH HISTORY
How would you describe your overall health? Generally good
below.
Do you have any recurrent medical conditions such as allergies
If yes, please list:

16. Please list below current medical problems, physical
limitations, sleep problems, unusual eating habits, poor hygiene,
overall physical fitness, head injuries, early childhood
infections, eating disorders, knee or back injuries, asthma, etc.
Medical Conditions
Are you currently
receiving
treatment?
Provider
Does this condition
cause stress or
impairment at this
time?
What have you found
that helps?
High blood pressure Yes Dr. Medicine Yes-I need to be more
consistent on my
medication which
stresses me out but the
stress I am under leads
me to forget

17. I just need to stay on my
medication as prescribed
Insomnia No Yes-I find it very hard
to go to sleep or stay
asleep
Nothing
Lack of appetite No Yes, but only because
I know I should be
Trying to eat when my
kids eat
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Please list medications (including psychotropic,
over‐ the‐ counter, herbal remedies) that you have taken in the
past 6 months.

18. Medication Dosage Frequency Prescribed By
Reason for
Medication
Diuril 500mg 2x/day Dr. Medicine High Blood Pressure
No, please explain: I have trouble remembering to
take it consistently. I usually remember at least one dose per
day, but with all that is going on, I frequently forget.
Symptoms start fairly quickly and then I get angry at myself and
this whole situation.
Additional information (if needed):
Have you ever had a serious accident/illness or hospitalization?
Please list all past hospitalizations, surgeries, accidents, or
illnesses in the chart below.

19. Reason for Previous Hospitalizations, Accident, Illness
Date/Location of Hospitalization
Traumatic rape December 2012/General Hospital
Childbirth July 2012/Local Hospital
Childbirth June 2010/Local Hospital
Car wreck November 2006/City Hospital
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Primary Care Doctor: Dr. Medicine Facility: Medicine Family
Practice Phone Number: 000-123-9876
ALCOHOL/DRUG ASSESSMENT:
complete table below. If no history, move
to next section.
most every time

20. Have you ever had to increase the amount of alcohol/drug you
consume to get the same effect?
don’t currently drink but did in my early twenties.
I also drank quite a bit after my rape experience and this is
when it escalated
No If yes, when was the last OD?
Have you ever experienced
With whom do you typically consume alcoh
‐
Have you ever experienced problems related to your alcohol
If yes, please describe: When I was drinking after the rape, I did
so to excess. It caused a lot of problems for me
at home and work. I quit drinking as part of my therapy process
and have been sober since.

21. LEGAL INVOLVEMENT:
Please indicate by checking below your legal status.
Charges: Probation/Parole Officer’s Name:
Contact #:
Additional Information:
HISTORY OF ABUSE/NEGLECT:
please complete the chart below.
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Type of Abuse By Whom? At What Age? Was it Reported?

22. No
What else do you feel is important for us to know?
I don’t see my mother as a bad person. She’s more the product
of how she was raised. I knew she loved me and I know
my dad did too. They were just “kids” playing the role of
parents. I love my mother as person and hate what she has
gone through in her own life. We just won’t ever be close.
HISTORY OF VIOLENCE:
Have you ever been accused of abusing or assaulting someone?
Type of Abuse To Whom? At What Age? Was it Reported?

23. What else do you feel/believe is important for us to know?
STRENGTHS/RESOURCES/SUPPORTS:
What limitations do you have (if any)? Financial, no “mom” to
make things okay
What strengths do you have? My kids. I’m a good mom and I
love my kids more than anything. I’m a generally good
person who people like to be around.
What resources do you have to help with your current problem?
My husband and his family, friends
What experiences (past & present) will help you in improving
the current situation?
I know I made it through something devastating before so I can
again. I know counseling helped. I know I need to seek
help from others who care. It’s just hard. There are days I think
this is just too much, and I will never make it through.

24. What are you (and your family) already doing to improve the
current situation?
I’m coming to counseling. My husband is working on getting
our house repaired.
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-workers
CURRENT NEEDS/GOALS
What do you feel is your biggest need right now? Coping with
Maria’s loss
What do you most hope to gain from coming to counseling?
Staying afloat, being a focused and worthwhile person
again.
If you were to pick three goals to work on, what would they be?
Goal 1: Working through the loss of Maria

25. Goal 2: Finding stability in our home life
Goal 3: Improving my outlook on life so I can plug back in at
home and at work
What else would you like for us to be aware of?
I was significantly impacted by my prior rape experience. I
have worked hard to overcome it, but it was a violent
and emotionally, mentally, and physically devastating
experience for me.
INDIVIDUAL COMPLETING ASSESSMENT
Printed Name Sabrina Hinajosa Date: Today
Signature Sabrina Hinajosa