Biopsychosocial Assessment
____ Part 1 (Topic 2)
Template
____ Part 2 (Topic 3)
Name:
______________________________ Date: _________________ DOB: ________________
Age: ________________________________ Start Time: ____________ End Time: ___________
Identifying Information:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Presenting Problem:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Life Stressors:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Substance Use: FORMCHECKBOX
Yes FORMCHECKBOX
No
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Addictions (i.e., gambling, pornography, video gaming):
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Medical/Mental Health Hx/Hospitalizations:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Abuse/Trauma:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Social Relationships:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Strengths:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Legal History:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Educational History:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Family Information:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Spiritual:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Suicidal:
________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________
Homicidal:
________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________
Mental Status Exam (MSE):
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Clinical Justification (Provide clinical justification related to client symptomology along with a DSM and ICD diagnosis based on client assessment):
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Initial Diagnosis (DSM 5):
________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________
Initial Treatment Goals:
Goal:
Objective:
Intervention:
Target Date:
Discharge Plan:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Name: _____________________________________________
Date: __________________
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