Psychosocial Screening Tool

1. Place label here
COPC SOCIAL WORK
PSYCHOSOCIAL SCREENING (Adult)
PLEASE COMPLETE AND RETURN TO CENTER RECEPTIONIST
Today's Date: Age
/ /
PLEASE DARKEN AREAS THAT HAVE BEEN CAUSING YOU STRESS THIS WEEK.
PRACTICAL CONCERNS FAMILY CONCERNS
Housing Problems Violence / Abuse
Financial Problems Dealing with partner
Legal Issues Dealing with children
Work Dealing with family members
School
Transportation
EMOTIONAL CONCERNS
Child Care
Recent Death / Loss
Worry / Stress
PHYSICAL CONCERNS
Fears/Anxiety
Coping with Pain
Sadness/ Depression
Coping with health problems
Nervousness
Want to quit smoking
Thoughts of killing yourself or others
Problems with drugs/alcohols
(Ask to see a Social Worker today)
Other_____________________
SPIRITUAL / RELIGIOUS CONCERNS
Spiritual / Religious Concerns
I HAVE NONE OF THIS CONCERNS TODAY
Person completing this form: Patient Other Indicate relationship to patient
Would you like to talk to a social worker about this issues? Yes No
If yes, please provide phone number .______________________________
FOR OFFICE USE ONLY
DISPOSITION: REFERRAL:
Same Day Appointment Internal
Phone Assessment
External
Patient Contacted - Appointment Scheduled
Patient Contacted - Appointment Declined
Unable to Contact
Social Worker's Signature/ID # Date /Time
Revised 5/11/09 2457591294