Psychologist Template

Pre assessment <18yrs

A professional Psychologist template for healthcare professionals.

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Specialty

Psychologist

Used

8 times

Type

Note

Last edited

13/04/2026

Created by

Amy Shallis

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About this template

This 'Pre-assessment <18yrs' template is designed for psychologists working with young people. It's a comprehensive tool for gathering essential information before a full assessment. The template covers key areas like presenting concerns, mental status, family history, and impact on daily functioning. This template is ideal for gathering information about a young person's mental health and well-being. Using Heidi, this template can be quickly populated from a session transcript, saving valuable time and ensuring all crucial details are captured. The date of this assessment is 1 November 2024.

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Reason for Assessment: Patient referred by GP due to concerns regarding low mood and social withdrawal. Mental Status Exam: Appearance: Appears stated age, well-groomed. Behaviour: Restless, fidgeting. Speech patterns: Monotone, slow speech. Mood: Low. Affect: Restricted. Thought process: Linear. Orientation: Oriented to person, time, and place. Previous/Current Engagement with Services: Client reported no previous engagement with psychologist. Client reported no historical and/or current engagement with allied health services. Client reported no historical and/or current engagement with a paediatrician. Client reported no historical and/or current engagement with a psychiatrist. Diagnostic Information: Client reported no diagnoses. Current Medications: Client reported no prescribed medication. Presenting Concerns: "I feel sad most of the time," the client stated. "I don't enjoy seeing my friends anymore." Impact on Functioning: Sleep: Difficulty falling asleep. Social: Client reports withdrawing from social activities and feeling isolated. Medical History: Client reported no concerns regarding vision. Client reported no concerns regarding hearing. Client reported no serious medical conditions. Family History: Client reported no family history of mental health conditions. Trauma History: Client reports no traumatic events. Pregnancy and Birth: No complications reported during pregnancy or birth. Early Development: No reported concerns regarding developmental milestones. No reported concerns regarding client's sleep pattern. No reported concerns regarding client's eating habits. No reported concerns regarding client's toileting skills. School Environment: Current school: St. Mary's High School Year: Year 9 Academic Functioning: Presenting symptoms are not reported to impact academic functioning. Assessment Plan: Client's pre-assessment will be discussed at the Lighthouse Psychology Practice's assessment meeting. Assessment goals: To assess the severity of the client's low mood and social withdrawal. Proposed questionnaires: Beck Depression Inventory (BDI-II), Social Avoidance and Distress Scale (SADS).