Occupational Therapy Psychosocial Assessment Form

Shishu Polli Plus (The Sreepur Village)

Client’s consent: verbal Signature:
Date of admission: 27/11/2021 Date of assessment: 26/09/2023

General information:
Client’s Name: Lubna Akter Age: 14 years Sex: Female
File No: 3752 House Name: Big Girls House
Education: Class 5 Marital status: Unmarried
Religion: Islam Job status: Student
Habit: Good: Substance abuse: No
Bad: Excessive tension of future and about family
Address: Village:Kirdarpur P.O: Fatepur
PS: Bisbwombapor District: Sunamgonj
Where you might live when reintegrate in the community: : Kirdarpur, Sunamgonj
Access road type: Pitched
House type: Tin shed
Health status: (Good):

Physical disability: The client has no physical disability.

Relevant medical history: No relevant medical history was found.
Received any medical treatment for this: (if there is a medical history)

Predisposing Factor:
History of abuse: (if any, then explain)

Physical: No.

Sexual: Yes, by father of friend.

Emotional: Yes, by friends, mother.

Neglect: Yes, by friends.

Bullying: Yes, by mother.

Ritualistic: No
Occupational Therapy Assessment:
Occupational History (current):
Education: Student of class 5
Job History: Study
Roles: Sister of 3 siblings, student.
Leisure: Gossiping, reading story book.
Daily Routine:
● 6.00am- Wake up
● 6.30am- arrange bed room and other works, self-care.
● 7.00am-8.30am-Study
● 8.40am- Going to school.
● 10:00am-3:30pm- Assembly, class
● 4:00pm- Going to home
● 4.20- takes snacks
● 5.00pm-6.00pm- Play with friends.
● 6.00pm-8:00pm- Study.
● 8.00pm-9.00pm- Take dinner.
● Go to sleep- 10.00pm/11;00pm/1:00am
General Observation: (According to the therapist)
Dress up: Client was well dress up, her clothes were neat and clean and socially appropriate.
Posture: Client maintained normal posture throughout the session.
Attention: Client has good attention span.

Work:
Plan for employment: Client wants to be a doctor.
Social History:
⮚ Describe the client socially. Please check all that apply
✔ Friends seek her out to play.
✔ She seeks others out to play.
o Makes friends easily.
o She prefers to play alone.
o Has difficulty making friends.
o Plays cooperatively with friends.
o Bullies’ other kids.
o Is picked on often.
o Is demanding and bossy.
✔ Plays with friends.
⮚ How many friends does the client have?
10
……………………………………………………………………………..
⮚ Does the client have a best friend?
✔ Yes
o No
o If yes, first name:Ellma
⮚ How does client get along with non-parent adults? Please check all that apply
o Friendly
✔ Cooperative.
o Disobedient Disrespectful
o Obedient
o Better behaved than with parents
o Adults like my child
o Other
⮚ How does client get along with siblings? Please check all that apply
o Protective
o Frequent fighting/arguments
o Won't share
o Jealous
 o Ignores them
o Plays well
✔ Take care of them

Academic History
⮚ Has the client repeated a grade?
o Yes
✔ No.
o If yes, which year(s)?
⮚ Does the client have a learning disability?
o Yes
✔ No.
o If yes, explain
⮚ Does the client have an IEP?
o Yes
✔ No
⮚ What school subject(s) does the client enjoy/thrive in?

English, Mathematics

…………………………………………………………………………………
⮚ What school subject(s) does the client dislike or struggle with?
Science
……………………………………………………………….……………………………..
 Cognitive skills: (Normal/Impaired/Poor)
Name Normal Impaired Poor Comments

Level of arousal ✔

Attention span ✔

Orientation Time ✔

Place ✔

Person ✔

Recognition ✔

Problem solving ✔ As she is

unable to cope
up with
difficult
situation of her
personal issues.

Able to follow ✔
instruction

Memory Long ✔
term

Short ✔
term

Identification Name ✔

Shape ✔

Color ✔
 Psychosocial Skills: Good / Poor/ Impaired
Components Good Poor Impaire Comment
d

Dynamic Need ✔

Emotions ✔ Emotionally sensitive due to

personal and family
background

Values ✔

Interest ✔

Motivation ✔

Social Social ✔
Function Interaction

Interpretation of ✔
situation

Social Skills ✔

Communication ✔

Dyadic ✔
interaction

Group ✔
interaction

Structured Co-operation ✔
social
Competition
interplay:
Compromise ✔

Negotiation ✔

Assertiveness ✔
Self-concept: Identity ✔

Sexual identity ✔

Body image ✔

Self-esteem ✔

Knowledge of ✔
one’s assets and
limitations

Self- Volition ✔
discipline:
Self-control ✔

Self- ✔
responsibility
and direction

Dealing with ✔ Faces difficulty to dealing

adversity with anxiety

Concept of ✔
others

Insight: ✔

Defense ✔ Unable to cope up with

Mechanism: anxiety as she has suicidal
thought

Object ✔
relation:

Reality ✔
testing:
Behavior: (Aggressive/Hyperactivity/Interactive with others/responsive/disciplined) Other
behaviors: Responsive behavior with siblings.

Perceived Stress Scale

The questions in this scale ask you about your feelings and thoughts during the last month. In
each case, you will be asked to indicate by circling how often you felt or thought a certain
way.
0 = Never
1 = Almost Never
2 = Sometimes
3 = Fairly Often
4 = Very Often
Questions Never Almost Some-times Fairly Very
often often
never

1. In the last month, how ✔

often have you been upset
because of something that
happened unexpectedly?

2. In the last month, how ✔

often have you felt that you
were unable to control the
important things in your life?

3. In the last month, how ✔

often have you felt nervous
and “stressed”?

4. In the last month, how ✔

often have you felt confident
about your ability to handle
your personal problems?
5. In the last month, how ✔
often have you felt that things
were going your way?

6. In the last month, how ✔

often have you found that
you could not cope with all
the things that you had to do?

7. In the last month, how ✔

often have you been able to
control irritations in your
life?

8. In the last month, how ✔

often have you felt that you
were on top of things?

9. In the last month, how ✔

often have you been angered
because of things that were
outside of your control?

10. In the last month, how ✔

often have you felt
difficulties were piling up so
high that you could not
overcome them?

Figuring Your PSS Score

You can determine your PSS score by following these directions:
● First, reverse your scores for questions 4, 5, 7, and 8. On these 4 questions, change
the scores like this:
0 = 4, 1 = 3, 2 = 2, 3 = 1, 4 = 0.
● Now add up your scores for each item to get a total. My total score is 29.
● Individual scores on the PSS can range from 0 to 40 with higher scores indicating
higher perceived stress.
 ✔ Scores ranging from 0-13 would be considered low stress.
✔ Scores ranging from 14-26 would be considered moderate stress.
✔ Scores ranging from 27-40 would be considered high perceived stress.
The Perceived Stress Scale is interesting and important because your perception of what is
happening in your life is most important. Consider the idea that two individuals could have
the exact same events and experiences in their lives for the past month. Depending on their
perception, total score could put one of those individuals in the low stress category and the
total score could put the second person in the high stress category.

Suicide Risk Review

Are you having thoughts of suicide? Yes

Current factors-
No
Current suicide plan

Pain (Do you have pain that something feels Yes

unbearable)

Resources (Do you feel you have few, if any, No

resources?)

Background Factor-
No
Prior suicidal behavior

Mental health Yes

 Sleep assessment
Informal assessment by asking some questions. These are examples of questions you can ask
your patient to gain a good understanding of their sleeping problem:

1. How many hours per night do you sleep?

5/6/7 hours

……………………………………………………………………………..
2. How long does it take you to fall asleep?
20 minutes
……………………………………………………………………………..
3. Are you able to stay asleep once you’ve fallen asleep?
This happen once a month.
……………………………………………………………………………..
4. Do you feel tired during the day? How is this impacting your work, leisure, and
socializing?
Feel tired during household work such as washing her cloth etc.
……………………………………………………………………………..
5. Do you drink caffeine, smoke, or take drugs?
No.
……………………………………………………………………………..
6. Are you taking any sleeping aids?
No.
……………………………………………………………………………..
7. Describe to me your sleeping environment?
There are 4 people in one room, one bed is over the another bed.
……………………………………………………………………………..
8. Do you sleep at regular times daily?
No.
……………………………………………………………………………..
9. What do you do for the hour before you go to bed?
Self-care, arrange the bed, washing the box of food etc,
……………………………………………………………………………..
Identified Occupational Needs (Strength/ Limitation/ Motivational
Factors):
● Strength:
● Limitation:
● Motivational factors:

Occupational Performance
(According to COPM)
Importance: (rate on a scale of 1-10 the importance of each activity)

Importance Performance Satisfaction Performance Satisfaction 2

1 1 1 2
ADLs
Eating 10 10 09

Bathing 10 10 10
Grooming 10 10 10
Dressing 10 10 10
Toileting 10 10 10

Personal 10 10 10
hygiene

Functional 9 10 10
mobility
Sexual
activity
IADLs
Care of others 10 10 10
Child rearing
Communication 9 8 10
management

Financial 10 10 10
Management
Health 10 9 10
management
and
maintenance
Home 10 9 10
establishment
and
management
Meal 10 10 10
preparation and
clean up
Religious 10 10 10
observance
Safety and 5 5 6
emergency
maintenance
Shopping 10 8 10
Community 10 9 10
mobility
Rest and sleep 8 6 7

Education 10 10 10
Work 10 10 10
Leisure 8 9 9
Social 10 10 10
participation

Scoring:

Total score = Total performance or satisfaction Scores / number of problems =

Performance Score 1 =

Satisfaction Score 1 =

Performance Score 2 =

Satisfaction Score 2 =

Changes in performance = (Performance Score 2 - Performance Score 1) =

Changes in Satisfaction= (Satisfaction Score 2 - Satisfaction Score 1)

Afsana Mim
3rd year, B.Sc. in Occupational Therapy
BHPI, CRP, Savar Afsana Mim
Occupational Therapist Signature