Create Your Own Psychosocial Directive.
Credit for this form goes to Michelle Puetz, Gerontology student Spring 05.
Advance Psychological Directives record anything of personal significance, including details such as what you like to be called and preferences or aversions concerning food, music, clothing, hobbies, interests, care arrangements, and companions. Below is one example of a psychological directive. If you find others please email them to me at wards@arc.losrios.edu
Personal Background
1. Name, age, and date of birth, including any nicknames or names you prefer to be addressed as.
2. Residence, including location and setting, where you were born and raised, and any other residences throughout you lifetime that are of importance.
Family Background
1. Spouse, including name, length of relationship,
occupation, age, status.
2. Children, including names and ages, if any.
3. Grandchildren/ Great grandchildren, including names and ages, if any.
4. Parents, with mothers and fathers names and/or nicknames, age, occupations, and favorite childhood memories.
5. Names and ages of any brothers and sisters.
6. Any special family traditions, celebrations that are an important part of your life.
Education and Occupation Background
1. Name and location of each school attended and degree
received.
2. Describe the occupations held during your life, as well
the occupation held for the longest period of time and during what years. What was the least enjoyed, and the most enjoyed.
3. Any military service, explaining duties, responsibilities,
any memories, awards, and recognitions.
Social and Activity Background
1. Religion or Denomination, importance of related activity, and ways to nurture your spirituality (through reading, music, rosary, nature, etc.).
2. Social organizations or groups such as clubs, community, or volunteer work.
3. Any close friends, including names, where they live, shared activities, and what their current involvement is.
4. What did you do for leisure time in the past and present.
5. Any preferences to being involved in group setting, as opposed to being alone.
6. Any interests you like in the present or past. Such as: sewing, cooking, cleaning, gardening, collection, arts and crafts, cars, woodworking, music, visiting others, books, newspapers, pets. If you enjoy physical activities such as, walking or sports. Any outings you enjoy such as, movies, shopping, and/or music. Any entertainment you might enjoy such as, games or TV programs.
7. Describe any activity that brings the most enjoyment, and any activity that would not be enjoyable.
Daily Routine
1. What time is preferred as a wake-up call, any napping
preferences, including location, and preferred bedtime. Also please describe any sleeping patterns, or any comforts you like.
2. What kind of bathing preference, preferred time, and
frequency.
Mealtimes
1. Typical foods you like for breakfast, lunch,
dinner, and snacks.
2. List any foods that should be avoided.
Clothing
1. Any clothing that may be used as a comfort. Such as a
favorite sweater, or certain type of clothing you enjoy wearing.
2. What type of clothing do you usually wear during the
day, and then at night.
Behavior
1. List any unusual behavior patterns, and anything that
can help with these unusual behaviors.
2. List any things that agitate, and things that calm and
reassure.
3. List any words or expressions that you use frequently,
And what they mean.
4. List any traumatic experiences that trigger negative
experiences or emotions.
Other things that may help us to understand and engage therapeutic activities would be sight, hearing, taste, touch, and smell. All of these may offer relaxation and pleasant memories, others may not be as pleasurable. Noting all of these things can help in taking loving care of you and make everyone happy.