Psychosocial Assessment Form JHS SHS College

Christ the King College
Gingoog City
GUIDANCE CENTER
PSYCHOSOCIAL NEEDS ASSESSMENT FORM

-During the Covid-19 Pandemic-
Junior-Senior High School-College (Student)
Praised be Jesus and Mary!

The Guidance Center of Christ the King College is continuing with its advocacy and promotion in assisting the students to
achieve their fullest potential. In this time of pandemic, we would like to reach out to our students and know how they
are coping with the current situation and how they are handling the community quarantine and the “new normal
lifestyle ”. To enrich our character as resilient CKCians, we would like to assess the psychosocial well-being of the
students inorder for us to identify who needs immediate counseling. We would like to request you to answer this
Psychosocial Needs Assessment Form as we aim to evaluate the mental, physical, and emotional health of the students,
hence we can provide an efficient treatment goal if needed. An interview with the student will be conducted. Thank you.
Keep Safe! This is Strictly Confidential.
Student’s Complete Name: _Andrea Mariz C. Inoc______________________________________________________

Age: __16_______
Year/Course:__11-humss__________________ Gender: _f_ Male __Female

Religion:_Catholic___________________________
Marital Status: __._ Single ___ Married Contact/Mobile Number:

_09971277782____________________________
I. HOME
Where are you living now?

o Private residence
o Boarding/rooming house (no supervision provided)
o School or Dormitory
o Foster Home
o Other (specify) _______________________________________________
Family Composition:
Mother’s Name: _Rubiline C. Inoc_______________________________________________________________ Age:

__43_________
_._ Living with child __ Not living with child Employed Currently? __ Yes __ No
Place of Employment: ________________________________________ Occupation:
_OFW__________________________
Father’s Name: ___Manuel B. Inoc_______________________________________________________________ Age:
___43_________
_._ Living with child __ Not living with child Employed Currently? __ Yes __ No
Place of Employment: ________________________________________ Occupation:
___Driver________________________
Marital status of Parents: __._ Married ___ Separated ___ Widowed ___ Others
Who primarily raised the student? ________________________ Number of children: ___3_________________
Significant life events of the student:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Recent Losses:
__ Family Member __ Friend ___ Health __ Lifestyle __ Job __ Income __ Housing __ None
Nature of Loss? __________________ Other Losses: _____________________
Additional information (if needed):
__________________________________________________________________________________________________
__________________________________________________________________________________________________
II. FEELINGS AND BEHAVIORS
Never A few days About every Almost every Every day

(0 days) (1-2 days) other day (7 days)
day/half (5-6 days)
of the time
(3-4 days)
Did you have trouble falling asleep or
staying asleep?
Did you feel sad?
Did you have trouble relaxing?
Were you nervous, uptight, or worried?
Did you worry about your safety?
Were you irritable or grouchy?
Did you cry a lot?
Were you afraid of things?
Did you feel like you had no energy?
Did you want to be by yourself instead of
with others?
Were you happy one minute and then sad
or angry the next minute?
Did you have stomachaches, headaches, or
other aches and pains?
Did you think or worry about bad things
that you have seen or have happened to
you?
Did you have a hard time paying
attention?
Were you angry?
Did you have trouble following rules?
Were you bothered by any of these
feelings?
III. FUNCTIONING AND SOCIAL CONNECTEDNESS

For each of these statements, please indicate whether you strongly agree, agree, are undecided, disagree or strongly
disagree by placing a check (∕) that corresponds your answer.
Strongly Agree Undecided Disagree Strongly
Agree Disagree
I am able to handle my daily routine of life.
I get along with family members.
I get along with friends and other people.
I am doing well in school and/or work.
I am able to cope when things go wrong.
I am satisfied with our family life right now.
I am able to do things I want to do (and am allowed
to do).
IV. SUICIDAL IDEATION
Have you ever thought of harming yourself or trying to take your own life? ___ Yes ___ No
If No, proceed to the next section V.
Do you think or feel this way presently? ___ Yes ___ No
Can the thoughts of harm be managed? ___ Yes ___ No
High risk behaviors ___ None ___ Cutting ___ Anorexia/Bulimia ___ Head Banging ___ Self injurious behaviors
Other: _____________________________________________________________
V. ALCOHOL/SUBSTANCE ASSESSMENT
Does you use cigarette or smokeless tobacco? ___ Yes ___ No ___ Do not know
Does you use alcohol or drugs? ___ Yes ___ No ___ Do not know
Had you ever overdosed or passed out on alcohol or other drugs?
___ Yes ___ No If yes, when was the last overdose? __________________________________________
Have you ever experienced problems related to alcohol use? ___ Yes ___ No
Please describe: _________________________________________________________________________________
VI. OTHER CONCERNS
Check the area of concern on the child/student, if any:

___ None ___ Activities of daily living ___Academic ___ Family relationships ___ Social relationships ___ Safety
___ Cognitive functioning ___ Physical health ___ Impulse control ___ Social skills ___Sleep Patterns
___Concentration ___Appetite ___Anxiety ___Mood Swing
Describe other concern:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
How long has this problem been causing your distress? (please circle)
Before COVID-19 After COVID-19 1 – 6 Months 6 Months – 1 Year Longer than one year
VII. COPING SKILL/SUPPORT
What limitations/ weaknesses do you/ your family have (if any)?______________________________________________

What strengths do you/ your family have? __we have strength in Believing God.
____________________________________________________
What resources do you have to help with your current problem?
____________we’re just staying positive
_______________________________________________________________________________
What experiences (past & present) will help you in improving the current situation?
___________________________________________________________________________________________
___________________________________________________________________________________________
What are you (and your family) already doing to improve the current situation?
___________________________________________________________________________________________
Who do you count on for support? ___ Parents ___ Boyfriend/Girlfriend ___ Siblings ___ Extended Family
___ Friends ___ Neighbors ___ School Staff ___ Church ___ Therapist
Other: _________________________________________
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
VIII. CURRENT NEEDS/GOALS
What do you think is your biggest need right now?

__focus____________________________________________________
What do you most hope to gain from coming to counseling? ________________________________________________
If you were to pick three goals to work on, what would they be?
Goal 1: __confidence_____________________________________________________________________________
Goal 2: ___fucos____________________________________________________________________________
Goal 3: _______________________________________________________________________________
What else would you like for us to be aware of?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
COMPLETING ASSESSMENT
Name of Student completed the form __Andrea Mariz C. Inoc___________________________________ Date: ___09-
23-21__________________
Signature _________________________________________
Note: After completion, kindly e-mail this form at [email protected] or you may drop it at the
Guidance Center (CKC). We will give you a call for the interview or “kamustahan” session. Thank you. God bless.
Name of Interviewer: _________________________________________________ Date:______________________
Notes:

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Christ the King College

PSYCHOSOCIAL NEEDS ASSESSMENT FORM

Junior-Senior High School-College (Student)

Praised be Jesus and Mary!

Student’s Complete Name: _Andrea Mariz C. Inoc______________________________________________________

Year/Course:__11-humss__________________ Gender: _f_ Male __Female

Marital Status: __._ Single ___ Married Contact/Mobile Number:

Where are you living now?

Mother’s Name: _Rubiline C. Inoc_______________________________________________________________ Age:

II. FEELINGS AND BEHAVIORS

Never A few days About every Almost every Every day

III. FUNCTIONING AND SOCIAL CONNECTEDNESS

VI. OTHER CONCERNS

Check the area of concern on the child/student, if any:

VII. COPING SKILL/SUPPORT

What limitations/ weaknesses do you/ your family have (if any)?______________________________________________

VIII. CURRENT NEEDS/GOALS

What do you think is your biggest need right now?

Name of Interviewer: _________________________________________________ Date:______________________

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Year/Course:11-humss________________ Gender: _f_ Male __Female

Name of Interviewer: ___________________________ Date: