Online Bio Biopsychosocial Make Details

The biopsychosocial assessment social work form is an important document that social workers use to assess a client's overall psychological and physical health. This form can help social workers provide the best possible care for their clients. The form includes sections on demographics, medical history, psychiatric history, family history, and more. It is important for social workers to complete this form accurately and thoroughly to get a clear picture of their clients' health status.

The listing offers specifics of the biopsychosocial assessment social work form. There, you'll discover the details about the PDF you want to fill out, which includes the likely time for you to fill it out as well as other data.

QuestionAnswer
Form NameBiopsychosocial Assessment Social Work Form
Form Length7 pages
Fillable?Yes
Fillable fields490
Avg. time to fill out33 min 16 sec
Other namesbiopsychosocial assessment example pdf, biopsychosocial examples pdf, biopsychosocial spiritual assessment template, online bio biopsychosocial search

Form Preview Example

(include mid-life, senior/elder, other issues)

CONFIDENTIAL

To be completed by Network Providers:

Authorization Number:

Staff Member:

Division/Office:

Placer County Systems of Care

BIOPSYCHOSOCIAL ASSESSMENT

New

Update

Name of individual being assessed:

 

 

 

Date of assessment:

 

Who was present during assessment?

 

 

 

 

Location of assessment:

 

 

If minor, attach “Authorization to Treat Minor.”

1.Presenting Problem(s) and Requested Service(s):

A. What is the client's presenting problem / why are they here? (in client's own words when possible)

B.Describe precipitating events:

C. What service(s) is the client asking for?

2.Lifespan / Developmental History:

A.Health at birth:

B.Developmental milestones:

C.Special services received during lifetime:

D.Other lifespan / developmental issues:

Within normal limits (use this box for adults only, complete section if child)

CARE-015 Rev. 07/25/2006

Page 1 of 7

CONFIDENTIAL

Client Name:

 

Case Number:

3.Education and Occupation:

A.School currently attending, if applicable: __________________________________________ Grade: _________

B.Education history: (include learning problems, school issues). Highest grade completed:

C.Occupation and employment history: (present and past, include # of years worked, and reasons for periods of unemployment)

D.Occupational skills / training:

4.Family of Origin History:

A.Family’s current and past psychiatric history:

B.Family’s and client’s physical / sexual / emotional abuse history:

C.Family’s substance use / abuse history:

5.Client’s Current and Significant Past Social Supports, Family Supports, Significant Relationships, Religious and Spiritual Supports/Affiliations:

6.Other Agencies / Systems Client is Involved With or is Receiving Services From, i.e., Dept of Rehab., CalWORKs, ASOC, etc.: (include the name of the agency and primary contact person–ATTACH RELEASES)

7.Client's Legal History: (ATTACH RELEASES)

Informal Probation

Conservatorship

Formal Probation

D.U.I.

Parole

Restraining order

Child Welfare Services

None reported

(describe and, if currently involved, give name of probation officer, parole office, or case manager and estimated start and end dates)

CARE-015 Rev. 10/19/2006

Page 2 of 7

CONFIDENTIAL

Client Name:

 

Case Number:

8.Client's Substance Use: (alcohol and other drugs, check all that apply)

A.

No substance use reported

Caffeine

Tobacco Over-the-counter medication Prescription medication Other; please identify:

Alcohol

Inhalants

Hallucinogens

Marijuana

Stimulants

Sedatives

Tranquilizers

Cocaine

Barbiturates

Methamphetamines

Opiates

Methadone

Substance

Age of

1st Use

Amount/

Frequency

Duration

of Use

Date of

Last Use

Period of

Heaviest Use

Amount Used in

Last 24 hrs.

B.

Does client have a history of withdrawal, DTs, blackouts (loss of time), seizures, etc.?

Yes

C.Ask the client "What happens when you stop using?" What is the response?

No

D.What is the longest period of sobriety? _______________ When? _______________________________________

E.Has the client received treatment for drug or alcohol issues? Yes No (ATTACH RELEASES)

(if yes, list in-patient providers, out-patient, providers, services received, dates of service; and outcomes)

9.Client's Mental Health Services History: (ATTACH RELEASES)

A.Current and past psychiatric history:

Client reports no psychiatric history

B.Current service provider(s):

C.Past service provider(s): (include in-patient, out-patient; provider names, dates, therapeutic interventions and outcomes)

CARE-015 Rev. 10/19/2006

Page 3 of 7

CONFIDENTIAL

Client Name:

 

Case Number:

10.Medical History: (document significant past and present medical conditions, including allergies) (ATTACH RELEASES)

Client reports no outstanding medical problems

Client reports no known allergies

Client reports the following medical conditions:

Primary Care Physician’s name and phone #:

Date of last physical examination:

List alternative treatments/therapies: (i.e., biofeedback, acupuncture, hypnosis, etc.)

11.If Lab Tests Were Done, Describe Results:

Not applicable

12.Medication History: (ATTACH RELEASES) A. Current psychiatric medications:

None reported by client

 

 

 

Dose/

Benefit/

Prescribed By:

 

When

 

 

When is Next

 

 

Drug Name

 

 

 

 

 

 

 

 

 

 

Frequency

Side Effects

(Dr.'s Name)

 

Prescribed?

 

 

Refill Required?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B. Past psychiatric medications:

None reported by client

 

 

 

 

 

 

 

 

 

Dose/

Benefit/

Prescribed By:

 

When

 

 

When is Next

 

 

Drug Name

 

 

 

 

 

 

 

 

 

 

Frequency

Side Effects

(Dr.'s Name)

 

Prescribed?

 

 

Refill Required?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C. Other medications:

None reported by client

(include non-psychiatric prescriptions and alternative medications, i.e., homeopathic, herbal remedies)

Drug Name

Dose/

Frequency

Benefit/

Side Effects

Prescribed By:

(Dr.'s Name)

When

Prescribed?

When is Next

Refill Required?

D. Medication allergies or adverse reactions:

None known—per client report

Drug Name

Reaction

E. Does client follow medication regime?

Yes

No Explain: ___________________________________________

CARE-015 Rev. 10/19/2006

Page 4 of 7

CONFIDENTIAL

Client Name:

 

Case Number:

13.Current Symptoms/Problems: (rate severity and duration for each)

Key:

Severity Rating:

 

1 = Mild

 

 

2 = Moderate

3 = Severe

 

 

 

 

Duration Rating:

 

1 = Less Than 1 Month

2 = 1 - 6 Months

3 = 7 - 11 Months

 

4 = More Than 1 Year

 

 

 

 

 

 

 

 

Severity

 

Duration

 

 

 

 

Severity

 

Duration

1.

Anxiety

 

 

 

 

 

15.

Bizarre Ideation

 

 

 

 

2.

Panic Attacks

 

 

 

 

 

16.

Bizarre Behavior

 

 

 

 

3.

Phobia

 

 

 

 

 

 

17.

Paranoid Ideation

 

 

 

 

4.

Obsessive Compulsive

 

 

 

 

 

18.

Gender Issues

 

 

 

 

5.

Somatization

 

 

 

 

 

19.

Eating Disorders

 

 

 

 

6.

Depression

 

 

 

 

 

20.

Poor Judgement

 

 

 

 

7.

Impaired Memory

 

 

 

 

 

21.

Lack of Support System

 

 

 

 

8.

Poor Self Care Skills

 

 

 

 

 

22.

Poor Interpersonal Skills

 

 

 

 

9.

Loss of Interest

 

 

 

 

 

23.

Conduct Problems

 

 

 

 

10.

Loss of Energy

 

 

 

 

 

24.

School Problems

 

 

 

 

11.

Sexual Dysfunction

 

 

 

 

 

25.

Family Problems

 

 

 

 

12.

Sleep Disturbance

 

 

 

 

 

26.

Indep. Living Problems

 

 

 

 

13.

Appetite Disturbance

 

 

 

 

 

27.

Unusual Body Movements

 

 

 

 

14.

Weight Change

 

 

 

 

 

28.

Other: _________________

 

 

 

 

Please describe symptoms / problems above in detail:

14.Mental Status: (please describe client's physical appearance, motor behavior, eye contact, mood, affect, speech pattern, thought processes, thought content, audio / visual / tactile hallucinations, intelligence, insight, judgment, and orientation)

15.Assessment of Risk:

A. Current risk factors: (check all that apply)

Suicidality:

None

Ideation

Plan

Homicidality:

None

Ideation

Plan

If risk exists, client is able to contract not to harm:

Self

Impulse control:

Sufficient

Moderate

Minimal

Substance abuse:

None

Abuse

Dependence

Medical risks:

No

Yes If “Yes”, explain:

Intent w/o means

Intent w/o means

Others

Inconsistent

Unstable remission

Intent with means Intent with means

Explosive

B.Risk history: (explain any significant history of suicidal, homicidal, impulse control, medical or substance abuse behavior that may affect client's current level of risk or impairment to functioning. Include description of plan / ideation / intent checked above)

16.Describe Client Strengths in Achieving Case Plan / Treatment Goals:

CARE-015 Rev. 10/19/2006

Page 5 of 7

(mandatory)

CONFIDENTIAL

Client Name:

 

Case Number:

17.Summary of Findings / Formulation: (identify problem areas and underlying dynamics. Include information used to make differential diagnosis.)

18.Recommended Services: (check all that apply.)

Community referrals made, no further services needed.

Medication assessment

By Primary Care Physician By ASOC or CSOC Psychiatrist

Individual therapy, frequency recommended is _____ times per month . Brief therapy

Long-term therapy

Family therapy

Collateral, describe reason: ___________________________________________________________________________

Group, specify type: ________________________________________________________________________________

Testing, specify type: (i.e., Conner's, Beck, etc.) ___________________________________________________________________

Day rehab / treatment

Other, specify: _____________________________________________________________________________________

19.Services Provided:

A.If community referrals were made, please describe:

None

B.If client was placed on a 5150, please give details: (i.e., which hospital, how transported, etc.)

Not applicable

20.Are the Following Documents Attached?

Releases as needed

Authorization to Treat a Minor (mandatory for all minors under 12, minors 12 and older may consent for treatment if certain conditions apply)

Client Services Information Coversheet, CARE-015a

Outcome Screen, CARE-011 or 012 (mandatory)

Periodic Information Sheet, CARE-024 (mandatory)

Test results or other related/relevant documents

Assessment completed by:

 

 

 

 

 

 

 

 

Counselor/Clinician/Practitioner Signature:

 

 

 

 

 

 

 

 

(include licensure, degree, or job title):

 

 

 

 

 

Date:

 

 

 

Work Unit/

 

 

 

 

 

Print Name:

 

 

Organization:

 

Phone #

 

 

 

 

 

 

 

 

 

 

 

Placer County Use Only

 

 

 

 

 

Supervisor's Signature: ____________________________________________________________ Date: ____________________

Less Intensive - Managed Care Unit

More Intensive - ASOC

More Intensive - CSOC

No services needed, Close

CARE-015 Rev. 10/19/2006

Page 6 of 7

CONFIDENTIAL

Placer County Systems of Care

ICD-9-CM Diagnosis Form

Client Name:

 

Case Number:

Type of Diagnosis:

Admission

Discharge

Update

 

Axis I: Clinical Disorders; Other Conditions That May Be a Focus of Clinical Attention

(ICD-9-CM)

 

 

 

 

 

.

 

 

 

 

 

 

a.

 

 

.

 

 

 

 

 

 

b.

 

 

.

 

 

 

 

 

 

c.

 

 

.

 

 

 

 

 

 

d.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Substance Abuse/Dependency:

 

 

 

 

 

 

 

Does a substance abuse/dependency issue exist?

Yes

No

Unknown/Not Reported

 

If yes, which substance disorder is the primary substance abuse diagnosis?

 

a

b

c

d

 

 

 

 

 

 

 

 

 

Axis II: Personality Disorders; Mental Retardation (ICD-9-CM)

 

 

 

 

 

 

 

 

.

 

 

 

 

 

 

e.

.

 

 

 

 

 

 

f.

Covered Axis I or Axis II Diagnosis:

Which Axis I or Axis II Diagnosis is the Medi-Cal covered ICD-9 Diagnosis?

a b c d e

f

 

 

 

 

 

 

 

 

 

 

 

 

 

 

General Medical Condition: Summary by Client Report or Medical Record Documentation

 

 

Allergies

Carpal Tunnel

 

Epilepsy/Seizures

 

 

 

Migraines

 

 

Physical Disability

Anemia

Chronic Pain

 

Heart Disease

 

 

 

Multiple Sclerosis

 

 

Psoriasis

 

Arterial Sclerotic Disease

Cirrhosis

 

 

 

Hepatitis

 

 

 

Muscular Dystrophy

 

 

STDs

 

Arthritis

Cystic Fibrosis

 

Hypercholestoralemia

 

 

No General Medical Condition

 

 

Stroke

 

Asthma

Deaf/Hearing Impaired

 

Hyperlipidemia

 

 

 

Obesity

 

 

 

 

Tinnitus

 

Birth Defects

Diabetes

 

 

 

Hypertension

 

 

 

Osteoporosis

 

 

Ulcers

 

Blind/Visually Impaired

Digestive Disorders

 

Hyperthyroid

 

 

 

Other

 

 

 

 

Unknown/

 

Cancer

Ear Infections

 

Infertility

 

 

 

Parkinson’s Disease

 

 

Not Reported

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Axis IV: Psychosocial and Environmental Problems (DSM-IV TR). Check yes or no for each problem.

 

 

Primary Support Group

Yes

No

Occupational

Yes

No

 

Access to Health Care

Yes

No

Social Environment

Yes

No

Housing

Yes

No

 

Legal System/Crime

Yes

No

Educational

Yes

No

Economic

Yes

No

 

Other Problems

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Trauma:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has the client witnessed violence, lived through a natural disaster, been a combatant or civilian in a war zone,

Yes

 

witnessed or been a victim of a severe accident, or been the victim of physical, emotional, or sexual abuse?

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Unknown

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Axis V: Global Assessment of Functioning Scale (GAF – DSM-IV TR)

 

 

 

 

 

 

 

 

 

Current:

Highest in last 12 months:

 

 

 

Lowest in last 12 months:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Transcribed by:

 

 

 

 

 

 

 

 

 

 

 

Date:

 

 

 

Print Name of Diagnosing Practitioner:

 

 

 

 

 

 

 

Date:

 

 

(Must be Master’s level or above)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Licensed Practitioner:

 

 

 

 

 

 

 

 

Date:

 

 

 

(Must include licensure after signature)

CARE-015 Revised 01/03/2007

(CARE053 01/03/2007 = ICD-9-CM Diagnosis Form)

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