Provider/Practice Name

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Biopsychosocial Assessment

Demographics
Name: DOB: Today's Date:

Address:

City: State: Zip: Preferred Phone:

Email: Referred By:

Emergency Contact Name: Relationship:
Phone: Language Spoken:
Marital status: □Single □Married □Partnered □Divorced □Widowed □Separated
Race/ethnicity: □Hispanic/Latino □African American/Black/African/Caribbean □Asian/Pacific Islander
□Caucasian □Native American □No Disclosure □Other
Referral Source & Case Management
Referral Source:
Contact Info:

Case Manager:
Contact Info:

Sources of Data
□ Consultations with collateral contacts
□ Written materials
□ Records from referring agency
□ Diagnostic tests
□ Interviews
□
Page 1
Client Name:

Presenting Problem
Client's definition of presenting problem/need:

History of presenting problem:

Client's expectations for treatment/service:

Prior attempts to resolve problem:

Length of duration of problem:

□ □ □ 1-5 years □ 5+ years
1-6 months
Severity: □0 □1 □2 □3 □4 □5 □6 □7 □8 □9 □10 □+
Presenting problem symptoms:
□ Sadness □ Hopeless/helpless □ Sleep too much □ Fatigue/no energy
□ No motivation □ Lack of interest □ Thoughts of dying □ Guilt
□ Not hungry □ Prefer being alone □ Irritable/angry □ Can’t sleep
□ No need for sleep □ Talk too fast □ Impulsive □ Can’t concentrate
□ Suspicious □ Hearing things □ Seeing things □ Feel worthless
□ Paranoid □ Feeling nervous □ Fearful □ Panic attacks
□ Easily startled □ Avoidance □ Re-occurring nightmares □ Depression
□ Decreased appetite □ Increased appetite □ Poor memory □ Anxiety
□ Restless/can’t sit still □ People watching me □ Can’t be in crowds □ Mood swings
□ Headaches □ Sexual problems □ Fainting
□ Dizziness □ Skin problems □ Nausea Other:

□ Chest pains □ Rapid heartbeat □ Vision changes

□ Numbness □ Trembling/shaking □ Blackouts
□ Sweating □ Joint/muscle pain □ Chills/hot flashes
□ Shortness of breath □ Heat pounding □ Stomach aches
Page 2
Client Name:

Family Composition
Immediate family members of client:
Name Gender Age Relationship to Client Living with Client

□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
Family mental health history:

Mother Father Sister Brother Child Other

Depression □ □ □ □ □
Anxiety □ □ □ □ □
Bipolar Disorder □ □ □ □ □
Schizophrenia □ □ □ □ □
ADHD / ADD □ □ □ □ □
Trauma History □ □ □ □ □
Abusive Behavior □ □ □ □ □
Alcohol Abuse □ □ □ □ □
Drug Abuse □ □ □ □ □
Suicide □ □ □ □ □
Other □ □ □ □ □
Is client adopted □ Yes □ No
Pregnancy history: #Live Births #Stillbirths #Miscarriages

Experienced the loss of a child:

Recent loss/bereavement:
□ Family member □ Friend □Health □ Income □ Housing □ Relationship □ Pet □ Job
Page 3
Client Name:

Background & Current Functioning

Living situation:
□ Adequate housing□ Housing dangerous □ Ward of the State □ Dependent on others □ Homeless
□ Housing overcrowded □ Incarcerated □ At risk of homelessness □ Other:
Education/work history:
Years of Education Degree(s)
Currently Employed □ □ Yes No □ □
Satisfied Unsatisfied Been Fired □ Yes □ No
□ Full-time □ Seasonal□ Self-employed□ □
Part-time Temporary
□ Never employed □ Disabled □ Student □ Unstable work history
□ □ Problems with co-workers □ Other:
Financial situation:
□ No current problems □ Substantial debt □ Relationship conflicts over finances
□ Impulsive spending □ Poverty or below
□
Sources of income:
□ Employment □ Public assistance □ Retirement □ SSD □ SSDI □ SSI □ Medical disability
□ Other:

Military history:
Branch of service Combat □ □
Yes No
□
Type of discharge Honorable □ Dishonorable □ Medical □Other than honorable □ General
Overall perspective of time in service:

List of current disability status and services client is receiving from the Veterans Administration:

Sexual orientation:

Experienced stress or harassment due to sexual orientation □ Yes □ No

Page 4
Client Name:

Background & Current Functioning - Cont.

Legal situation:
Past or current legal problems □ □ No
Yes
□ □ Gangs □ □ Arrest □ Conviction □ Jail □ Probation □ Prison
Detention
Explanation:

Court ordered treatment:

Ordered By Offense Length of Time

Religious or spiritual involvement:

Leisure & recreation:

□ □
Reading Time with friends □ Sports/exercise □ Dancing □ Hobbies □ Watch TV/movies
□ Time with family □Classes □ Walking □ Stay at home □ Bars/clubs □ Listen to music
□
Limitations client may have in participating in leisure or recreational activities:

Social history & support:

□ □
Parents divorced? Yes No
Briefly describe childhood (happy, chaotic, troubled):

Page 5
Client Name:

Background & Current Functioning - Cont.

Are childhood events contributing to current problems □ Yes □ No

□
Satisfied with current family life □
Satisfied Unsatisfied
□
Satisfied with the support received from family and friends Satisfied □ Unsatisfied
□ □
Satisfied with quality of life Satisfied Unsatisfied
Strengths/Resources/Supports
What does client feel they do well?

What resources does client have to help with current problem?

What is the client (and their family) already doing to improve the current situation?

Who can client count on for support?

Strengths/Resources 1 = Adequate, 2 = Above Average, 3 = Exceptional

-- Family support         -- Social support systems -- Relationship stability
-- Intellectual/cognitive skills -- Coping skills & resiliency -- Parenting skills
-- Socio-economic stability     -- Communication skills       -- Insight & sensitivity
Maturity & judgment skills     Motivation for help         --
-- --
Notes:

Page 6
Client Name:

Medical Background
Primary Care Provider: Phone:

Medications:
Name Of Drug Dosage Purpose Frequency Prescribed By Began Taking

Surgeries:
Type of Surgery Date

Physical pain:
Experiencing pain□ □No
Yes
Location of pain
How long
Medication for pain
□ □ □2 □3 □4 □5 □6 □7 □8 □9 □10 □+
Pain level today 0 1
Nutrition concerns:
Weight Height Appetite □ Good □ Fair □ Poor

Purge □Yes □No Notes:

Restrict □Yes □No
Overeat □Yes □No
Binge □Yes □No
Hoarding □Yes □No

Page 7
Client Name:

Psychiatric & Psychological History

Hospitalizations for mental health purposes □ Yes □ No
Year Reason

Presently seeing a therapist/psychiatrist/psychologist □ Yes □ No

Trauma:
□ □
Physical abuse Sexual abuse □
Elder abuse □
Adult molested as a child □
Robbery victim
□ Assault victim □
Dating violence □
Domestic Violence □
Human trafficking □
Survivor of homicide
□ □ □
PTSD Rape victim Victim of stalker □
Car accident Other□

Abuse/neglect history:
Has client been abused or assaulted □ Yes □ No Is client in danger now □ Yes □ No
Type of Abuse By Whom What Age Was it Reported

Sexual □ Yes □ No
Physical □ Yes □ No
Emotional □ Yes □ No
Verbal □ Yes □ No
Abandoned □ Yes □ No
Neglected □ Yes □ No
Notes:

Page 8
Client Name:

Psychiatric & Psychological History - Cont.

Clients' history of violence:
Type of Abuse Explanation What Age Was it Reported

Sexual □ Yes □ No
Physical □ Yes □ No
Emotional □ Yes □ No
Verbal □ Yes □ No
Abandoned □ Yes □ No
Neglected □ Yes □ No
Notes:

Chemical abuse/use:
Drug Used Age First Used Age Heaviest Use Frequency & Amount Date Last Used

Alcohol

Cannabis/marijuana

Cocaine

Stimulants

Methamphetamine

Hallucinogens
Opioids

Sedatives

Designer Drugs
Tobacco
Caffeine

Drug of choice:

Ever injected drugs □ Yes □ No If yes, which ones

Page 9
Client Name:

Psychiatric & Psychological History - Cont.

Consequences of drug/alcohol use:
□ Sleep problems Seizures □ □ Binges Notes:
□ Hangover DUI's □ □ Liver disease
□ Overdose Homicide □ □ School dropout
□ Lost job Violent □ □ Arrests
□ Incarcerations Blackouts □ □ Relationship Issues
□ DTs/shakes GI bleeding □ □ Other
□ Increased tolerance Assaults □
Longest period of sobriety
Traded sex for drugs □ Yes □ No
Triggers to use
Risky behaviors Addictive behaviors Notes:
□ Unprotected sex Sex □
□ Gang involvement Gambling □
□ Shoplifting Internet □
□ Drug dealing Shopping □
□ Reckless driving Video gaming □
□ Carrying/using weapon Plastic surgery □
□ Trespassing Thrill seeking □
□ Fighting Food □
Risk Assessment:
Client so distressed they seriously wished to end their life ................. □ Yes □ No
□ Yes □ No
□ Yes □ No
Is there a specific plan for how client would kill themself .....................
Does client have access to weapons/means of hurting self .................
□ Yes □ No
History of serious suicide attempt ............................................................
□ Yes □ No
Has client purposely done something to hurt themselves .....................
□ Yes □ No
Does client hear voices telling them to hurt themselves ......................
□ Yes □ No
Does client have relatives who attempted or committed suicide .........
□ Yes □ No
Does client have thoughts of killing or seriously hurting someone ...... □ Yes □ No
Does client hear voices telling them to hurt others ............................... □ Yes □ No
Does client self-harm ................................................................................. □ Yes □ No
Risk to self □
Low Medium□ □
High □
Chronic
Risk to others □ Low □ Medium □ High □ Chronic
Serious current risk of any of the following (immediate response needed)
Abuse or family violence □ □
Yes No
Psychotic or severely psychologically disabled Yes No □ □
Is there a gun in the home □ □
Yes No Plan Yes No □ □
Any other weapons □ □
Yes No Reviewed Safety Plan Yes □ □ No
Page 10
Client Name:

Brief Mental Status Evaluation

Appearance Judgment Insights Speech Thought Content
□ Appropriate □ Excellent □ Full □ Appropriate □ Hallucinations
□ Inappropriate □ Good □ Partial □ Slurred □ Delusions
□ Disheveled □ Fair □ Limited □ Rapid □ Paranoid
□ Poor □ Poor □ None □ Pressured □ Dissociation

Thought Process Mood Behavior Affect

□ Irrelevant detail □ Depressed □ Appropriate □ Expansive
□ Disorganized □ Anxious □ Poor eye contact □ Euthymic
□ Interrupted thinking □ Irritable □ Distant/distracted □ Constricted
□ Loose □ Angry □ Hostile □ Blunt
□ Illogical connections □ Elevated □ Agitated □ Flat
□ False beliefs □ Euthymic □ Overly accommodating □ Dysphoric

Attitude to Examiner Intelligence

□ Seductive □ Mild retardation Global Functioning (GAF)
□ Playful □ Moderate retardation □ 10 Imminent harm
□ Ingratiating □ Severe retardation □ 20 Possible harm
□ Friendly □ Profound retardation □ 30 Serious impairment
□ Cooperative □ Dementia □ 40 Major impairment
□ Interested □ 50 Serious symptoms
□ Attentive □ 60 Moderate symptoms
□ Frank
Appropriateness
□ □ 70 Mild symptoms
□ Indifferent
□
Appropriate
□ 80 Slight impairment
□ Evasive
□
Inappropriate
□ 90 No symptoms
□ Defensive
Labile
□ 100 Superior function
□ Hostile
Notes:

Page 11
Client Name:

Client Goals/Needs
Self-identified top three goals:
1.

2.

3.

Self-identified top three needs:

1.

2.

3.

What does client hope to gain from therapy:

What else does client want examiner to know:

Page 12
Client Name:

Diagnosis & Interpretive Summary

DSM-5 Diagnosis: Clinical Disorder(s)
Diagnostic Code Disorder Name
Principal Diagnosis:

Subtypes & Specifiers: Severity:

Diagnostic Criterion:
A.

B.

C.

D.

E.

F.

G.

H.

DSM-5 Diagnosis: Clinical Disorder(s)

Diagnostic Code Disorder Name
Secondary Diagnosis:

Subtypes & Specifiers: Severity:

Diagnostic Criterion:
A.

B.

C.

D.

E.

F.

G.

H.
Page 13
Client Name:

Diagnosis & Interpretive Summary - Cont.

Assessment Tools Used:
1.

2.

3.

4.

5.
Notes:

Treatment acceptance/resistance:
Client accepts problem□ □ Yes No
□ □
Client recognizes need for treatment Yes No
□ □
Client minimizes or blames other Yes No
Referrals:
□ Psychiatrist □ Benefits coordinator □ Employment service
□ Psychologist □ Nutritionist □ Social worker
□ Medical provider □ Rehabilitation □ Community organization
□ □ Vocational counselor □ Other
Brief summary:

Page 14
Client Name:

Diagnosis & Interpretive Summary - Cont.

Impressions:

Goals & recommendations:

Examiner's Signature Date Page 15