Biopsychosocial Assessment

Identifying Information

Client Name

Gender

Date of Birth (Age)

Address

Phone Number

Marital Status

Race/Ethnicity/Nationality

Language

Referral Information

Referral Source

Referral Source Concerns

Presenting Concerns

Client's perception of the problem

History of the Problem

When did it start?

Prior Treatment

History of

DCS
Probation
Legal Trouble
Incarceration

Explain

Is client in crisis?

Assessment of Risk (i.e. suicidal, homicidal, ideation, plans, untreated mental health, etc)

General Description of Client

Appearance

Attitude

Affect

Problems with

Memory
Thinking
Speech
Reality

Signs of

Anxiety
Depression
Other moods

How did the client interact with you?

Family Composition & Background

Significant Other

Name
Age
Marriage Date
Deaths
Divorces
Describe Relationship
- Strengths
- Difficulties

Family Member

Name
Age
Current Location
Death
Describe Relationship

Education Background

School History

Current Status

Highest level completed

Degrees Earned

Special School & Education Talents

Challenges

Educational Goals

Employment & Vocational Skills

Occupation

Work History

Current Status

Special Training Skills

Religion & Spiritual Involvement

What religion do you identify with?

Level of Involvement?

Support from religious community?

Other spiritual practices or beliefs?

Military Background

Skip if no military experience

Branch Served

Client's Military Job

Dates served with deployments

Combat Experience

Impression of time served

Physical or mental health issues from the military

Civilian life adjustment

Disability from military

Medical Background

Physical Development

General Health

Disabilities

Current functioning

History of

Disease
Accidents
Genetic Predispositions

List of medications

Name of Medicine
For what?
Dosage/Frequency

Psychological and Psychiatric Background

History of mental health

What
Diagnosis by doctor or self diagnosis?
In treatment?
Symptoms
Age at which symptoms began
On medication for this?

If depression, complete Beck's Depression Scale or Edinburgh PPD Scale

Suicidal Ideation & Attempts

History of (details)
Current?

Complete Columbia Suicide Severity Rating Scale

Suicidal Ideation & Attempts

History of (details)
Current?

Complete Columbia Suicide Severity Rating Scale

History of vistimization Be specific (who perpetrated, at what age, currently happening?

Physical Abuse
Mental Abuse
Sexual Abuse
Domestic Violence
Neglect

If current IPV, copmlete DVSAT

History of perpetration Be specific (who victimized, at what age, currently happening?

Physical Abuse
Mental Abuse
Sexual Abuse
Domestic Violence
Neglect
Current HI, intent, means, plan?

If current IPV, copmlete DVSAT

Substance Abuse Background

History of substance abuse

Type of substance
At what age did first use start?
Mode of use
Frequency
Amount
How has use affected your life?
History of treatment
What symptoms do you experience?
Who do you use with?

History of treatment

How long have you been sober?
What are your triggers?
Do you feel ike this is still a problem in your life?

In what ways does your behavior concern you?

What do you think would work if you decided to stop using?

UNCOPE

Answer the questions to the right. In the last 12 months, have you:

Scoring:

Yes = 1 No = 0
2-3 indicates possible substance abuse
4 or more strongly indicate substance dependence
Scores of 2+ require a follow up

Score:

Social and Community Background

Important Friendships

How long?
Will they support a change?

Support Network

Who
Are they willing to participate and help through this process?

Community Resources

Do you use?
What do you use?
Are you aware of what is available?

Hobbies

What are they?
How often?
Can you afford them?

Basic Life Needs

Food Supply

Is this a constant worry?
Do you use food pantries?
Do you receive food stamps?

Housing

Stability
Habitability
Safety
Pest Control
Feelings about housing

Do you need assistance with food and/or housing?

If yes, type of need
Immediate Concern?

Legal Concerns

Immigrant Status

Live in fear?
Want help?

Housing

Evictions

Marital

Divorce
Child Custody

Domestic Violence

Department of Child Services

Parole/Probation

Current Charges
Felonies
Misdemeanors
Jail/Prison Experience

Environmental & Psychosocial Factors

Identity Issues

Discrimination

Sexual Harassment

Difficulties from handicap

Physical Handicap
Mental Handicap

Strengths, Capacities, Resources

Coping Skills

Strengths

Problem solving techniques

Limitations in dealing with current problem

Biopsychosocial Assessment Summary

Area of Functioning

Risk Factors

Strengths acquired or protective factors to build

Family Composition & Background

Education Background

Employment & Vocational Skills

Religious & Spiritual Involvement

Military Background

Medical Background

Psychological and Psychiatric Background

Substance Abuse Background & UNCOPE

Social & Community Background

Basic Life Needs

Legal Concerns

Environmental & Psychosocial Factors

Strengths, Capacities, Resources

GAD-7 Anxiety

Over the last two weeks, how often have you been bothered by the following problems?

	Not at all	Several days	More than half the days	Nearly every day

Total score: 0 / 21

Over the last 2 weeks, how often have you been bothered by any of the following problems?

	Not at all (0)	Several days (1)	More than half the days (2)	Nearly every day (3)

Total Score: 0

Child Depression Inventory (CDI)