Biopsychosocial Assessment Social Work Form – Fill Out and Use This PDF

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:

CONFIDENTIAL

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)

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

CONFIDENTIAL

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)

B.Current service provider(s):

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

CONFIDENTIAL

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.)

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

CONFIDENTIAL

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

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)

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:

CONFIDENTIAL

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.

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:

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

Supervisor's Signature: ____________________________________________________________ Date: ____________________

CONFIDENTIAL

Placer County Systems of Care

ICD-9-CM Diagnosis Form

Covered Axis I or Axis II Diagnosis:

(Must include licensure after signature)