Social History format
Presenting Problem/Current Psycho-Social Stressors-Include identifying data e.g. description of client, age, gender etc.
Why client is seeking services, length and duration of problem, how is the problem(s) impacting/affecting the client's life and functioning.
Talk about any other life stressors that might contribute to the problem. What does the client hope to gain from receiving services i.e. goals?
Mental Health/Substance Abuse History-Include information about previous counseling, personal history of mental illness, family history of mental illness, previous or current psychiatric treatment, hospitalizations.
Discuss history of substance abuse including family history, in or outpatient treatment, current drug usage etc.
Medical History-Include information about current medications, illnesses, diseases, surgeries, chronic or acute conditions, general health etc.