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The biopsychosocial template is a tool that can be used to assess and treat individuals who have experienced a traumatic event. The template incorporates information about the individual's biological, psychological, and social characteristics into one assessment. This information can be used to develop a treatment plan that addresses the individual's needs.

The following are some information about biopsychosocial template. You might want to read it prior to filling in the form.

Question	Answer
Form Name	Biopsychosocial Template
Form Length	10 pages
Fillable?	Yes
Fillable fields	1028
Avg. time to fill out	34 min 41 sec
Other names	biopsychosocial assessment template pdf, biopsychosocial template doc, biopsychosocial history questionnaire, biopsychosocial assessment template doc

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BIOPSYCHOSOCIAL ASSESSMENT

Demographics

Client Name:	Date:
Current Address:	Phone #: (	)	-
Street
City/State
Zip Code
Date of Birth:	Marital/Relationship Status:
Nation/Tribe/Ethnicity:
Primary language of client:			Secondary:
Referral Source:			Phone:
Emergency Contact:			Phone:

Family Relationships

Does the client have any children?

Name	Age	Date of	Sex	Custody?	Lives With?	Additional
		Birth		Y/N		Information

Who else lives with the client? (Include spouses, partners, siblings, parents, other relatives, friends)

Name	Age	Sex	Relationship		Additional Information








Primary language of household/family:				Secondary:
Family History
Family History of (select all that apply):
	Mother	Father	Siblings Aunt		Uncle	Grandparents

Alcohol/Substance Abuse

History of Completed Suicide

History of Mental Illness/Problems such as:

Depression

Schizophrenia

Bipolar Disorder

Alzheimer’s

Anxiety

Attention Deficit/Hyperactivity

Learning Disorders

School Behavior Problems

Incarceration

Other

Comments:

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BIOPSYCHOSOCIAL ASSESSMENT

Critical Population (choose all that apply)

Funding Source	Residential	Legal Involvement
Food Stamp Recipient	Homeless	Protective Services (APS/CPS)
TANF Recipient	Shelter Resident	Court Ordered Services
SSI Recipient	Long Term Care Eligibility	On Probation
SSDI Recipient	Long Term Care Resident	On Parole
SSA (retirement) Recipient		On Pre-Release
Other Retirement Income	Disability	Mandatory Monitoring
Medicaid Recipient	Physical Disability
Medicare Recipient	Severely Mentally Ill	Other
General Assistance	SED	Currently pregnant
	Developmentally Disabled	Woman w/dependents
	Chronically Mentally Ill
	Regional Behavioral Health Authority

Contact Information

(Secure consents for agency contacts, when possible)

Name of Caseworker	Agency	Phone number

Client’s/Family’s Presentation of the Problem:

Client’s/Family’s Expected Outcome:

Physical Functioning

Allergies (Medication & Other):

Current Medical Conditions:

Current Medications (include herbs, vitamins, & over-the-counter):

Past Medications:

Past Medical History including hospitalizations/residential treatment (list all prior inpatient or outpatient treatment including RTC, group home, therapeutic foster care, aftercare, inpatient psychiatric, outpatient counseling):

Dates

Inpt/Outpt

Location

Reason

Completed?

Y/N

Surgeries:

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BIOPSYCHOSOCIAL ASSESSMENT

Pain Questionnaire

Pain Management: Is the client in pain now?

Yes

If yes, ask client to rate the pain on a scale of 1-10 (with 10 being the severest) and

enter score here

Is the client receiving care for the pain?

Yes

If no, would the client like a referral for pain management?

Yes

Nutrition

Nutritional Status:

Current Weight

Current Height

BMI

Appetite:

Good

Fair

Poor, please explain below

Recently gained/lost significant weight

Binges/overeats to excess

Restricts food/Vomits/over-exercises to avoid weight gain

Special dietary needs

Hiding/hording food

Food allergies

Comments

Social

Supportive Social Network? (Rate the network using a scale of 1 Weak to 5 Strong)

Immediate Family

Extended Family

Friends

School

Work

Community

Religious

Other

Comment:

Living Situation:

Housing Adequate

Housing Dangerous

Ward of State/Tribal Court

Dependent on Others

Housing Overcrowded

Incarcerated

Homeless

At Risk of

Homelessness

Additional Information:

Employment: Currently Employed?

Yes

Employer

Length of Employment

Satisfied

Dissatisfied

Supervisor Conflict

Co-worker Conflict

Last Employer:

Reason for Leaving:

Never Employed

Disabled

Student

Unstable Work History

Financial Situation:

Presence or absence of financial difficulties: (Fields below are optional)

No Current Problems

Large Indebtedness

Relationship Conflicts Over Finances

Impulsive Spending

Poverty or Below

Financial Difficulties

Source of Income (choose all that apply)

Employed:

Full-time

Part-time

Unemployed:

Public Assistance

Seasonal

Temporary

Actively seeking work

Self-Employed

Not looking for work

Retirement

SSD

SSDI

SSI

Medical Disability via Employer

Other:

Military History:

Never enlisted in Armed Forces, OR

Branch of Service:

Combat:

Yes

Type of Discharge:

Honorable

Dishonorable

Medical

Other:

Sexual Orientation:

Heterosexual

Bisexual

Homosexual

Transgendered

N/A at this time

Comment:

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BIOPSYCHOSOCIAL ASSESSMENT

Family Social History

Describe family relationships & desire for involvement in the treatment process:

Perceived level of support for treatment? (scale 1-5 with 5 being the most supportive)

Legal Status Screening

Past or current legal problems (select all that apply)?

None	Gangs		DUI/DWI
Arrests	Conviction		Detention
Jail	Probation		Other:
If yes to any of the above, please explain:

Any court-ordered treatment?	Yes (explain below)	No
Ordered by	Offense		Length of Time

Education

Educational Level (select one):

less than 12 years – enter grade completed

Some college or tech school

Unknown

High School Grad/GED

College Graduate

If still attending, current School/Grade:

Vocational School/Skill Area:

College/Graduate School – Years Completed/Major:

Leisure & Recreation

Which of the following does the client do? (Select all that apply)

Spend Time with Friends		Sports/Exercise
Classes		Dancing
Time with Family		Hobbies
Work Part-Time		Watch Movies/TV
Go “Downtown”		Stay at Home
Listen to Music		Spend Time at Clubs/Bars
Go to Casinos		Other:

What limits the client’s leisure/recreational activities?

Functional Assessment

Is client able to care for him/herself?			Yes	No If No, please explain:

	Uses or Needs assistive or adaptive devices (select all that apply):
None		Glasses			Walker		Braille
Hearing Aids		Cane			Crutches		Wheelchair
Translated Written Information			Translator for Speaking			Other:
Does the client have a history of falls?			Yes	No Explain:

4 OF 10

REVISED 5/3/06

BIOPSYCHOSOCIAL ASSESSMENT

Psychological

History of Depressed Mood:

Yes

History of irritability, anger or violence (tantrums, hurts others, cruel to animals, destroys property):

Sleep Pattern: Number of hours per day			Time to onset of sleep?
Normal		Sleeping too much		Sleeping too little
Ability to Concentrate:		Normal	Difficulty concentrating
Energy Level:	Low		Average/Normal	High

History of/Current symptoms of PTSD (re-experiencing, avoidance, increased arousal)? Select all that apply

Intrusive memories, thoughts, perceptions	Nightmares	Flashbacks
Avoiding thoughts, feelings, conversations	Numbing/detachment	Restricted display of emotions
Avoiding people, places, activities	Poor sleep	Irritability
Hypervigilance	Other:

Any additional information:

Bereavement/Loss & Spiritual Awareness

Please list significant losses, deaths, abandonments, traumatic incidents:

Spiritual/Cultural Awareness & Practice

Knowledgeable about traditions, spirituality, or religion?				Yes	No Comment:

Practices traditions, spirituality, or religion?		Yes	No	Comment:

How does client describe his/her spirituality?

Does client see a traditional healer?	Yes	No	Comment:

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BIOPSYCHOSOCIAL ASSESSMENT

Abuse/Neglect/Exploitation Assessment

History of neglect (emotional, nutritional, medical, educational) or exploitation?	Yes	No
If yes, please explain:

Has client been abused at any time in the past or present by family, significant others, or anyone

else?)	No		Yes, explain:
	Type of Abuse			By Whom		Client’s	Currently
						Age(s)	Occurring? Y/N
Verbal Putdowns
Being threatened
Made to feel afraid
Pushed
Shoved
Slapped
Kicked
Strangled
Hit
Forced or coerced into sexual activity
Other
Was it reported?		Yes	No	To whom?
Outcome

Has client ever witnessed abuse or family violence?					No	Yes, explain:

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BIOPSYCHOSOCIAL ASSESSMENT

Behavioral Assessment

Abuse/Addiction – Chemical & Behavioral

Drug

Age First

Age Heaviest

Recent Pattern of Use

Date Last

Used

Use

(frequency & Amount, etc)

Used

Alcohol

Cannabis

Cocaine

Stimulants (crystal,

speed, amphetamines,

etc)

Methamphetamine

Inhalants (gas, paint,

glue, etc)

Hallucinogens (LSD,

PCP, mushrooms, etc)

Opioids (heroin,

narcotics, methadone,

etc)

Sedative/Hypnotics

(Valium, Phenobarb, etc)

Designer Drugs/Other

(herbal, Steroids, cough

syrup, etc)

Tobacco (smoke, chew)

Caffeine

Ever injected Drugs?

Yes

If Yes, Which ones?

Drug of Choice?

Consequences as a Result of Drug/Alcohol Use (select all that apply)

Hangovers

DTs/Shakes

Blackouts

Binges

Overdoses

Increased Tolerance

GI Bleeding

Liver Disease

(need more to get high)

Sleep Problems

Seizures

Relationship Problems

Left School

Lost Job

DUIs

Assaults

Arrests

Incarcerations

Homicide

Other:

Longest Period of Sobriety?

How long ago?

Triggers to use (list all that apply):

Has client traded sex for drugs?

Yes, explain:

Has client been tested for HIV?

Yes

If yes, date of last test:

Results:

Has client had any of the following problem gambling behaviors? Select all that apply:

Gambled longer than planned

Gambled until last dollar was gone

Lost sleep thinking of gambling

Used income or savings to gamble while letting bills go unpaid

Borrowed money to gamble

Made repeated, unsuccessful attempts to stop gambling

Been remorseful after gambling

Broken the law or considered breaking the law to finance gambling

Other:

Gambled to get money to meet financial obligations

Risk Taking/Impulsive Behavior (current/past) – select all that apply:

Unprotected sex

Shoplifting

Reckless driving

Gang Involvement

Drug Dealing

Carrying/using weapon

Other:

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BIOPSYCHOSOCIAL ASSESSMENT

Mental Status Exam

Category

Selections

GENERAL OBSERVATIONS

Appearance

Well groomed

Unkempt

Disheveled

Malodorous

Build

Average

Thin

Overweight

Obese

Demeanor

Cooperative

Hostile

Guarded

Withdrawn

Preoccupied

Demanding

Seductive

Eye Contact

Average

Decreased

Increased

Activity

Average

Decreased

Increased

Speech

Clear

Slurred

Rapid

Slow

Pressured

Soft

Loud

Monotone

Describe:

THOUGHT CONTENT

Delusions

None Reported

Grandiose

Persecutory

Somatic

Bizarre

Nihilist

Religious

Describe:

Other

None Reported

Poverty of Content

Obsessions

Compulsions

Phobias

Guilt

Anhedonia

Thought Insertion

Ideas of Reference

Thought Broadcasting

Describe:

Self Abuse

None Reported

Self Mutilization

Suicidal (assess lethality if present)

Intent

Plan

Aggressive

None Reported

Aggressive (assess lethality of present)

Intent

Plan

PERCEPTION

Hallucinations

None Reported

Auditory

Visual

Olfactory

Gustatory

Tactile

Describe:

Other

None Reported

Illusions

Depersonalization

Derealization

THOUGHT PROCESS

Logical

Goal Oriented

Circumstantial

Tangential

Loose

Rapid Thoughts

Incoherent

Concrete

Blocked

Flight of Ideas

Perserverative

Derailment

Describe:

MOOD

Euthymic

Depressed

Anxious

Angry

Euphoric

Irritable

AFFECT

Flat

Inappropriate

Labile

Blunted

Congruent with Mood

Full

Constricted

BEHAVIOR

No behavior issues

Assaultive

Resistant

Aggressive

Agitated

Hyperactive

Restless

Sleepy

Intrusive

MOVEMENT

Akasthisia

Dystonia

Tardive Dyskinesia

Tics

Describe:

COGNITION

Impairment of:

None Reported

Orientation

Memory

Attention/Concentration

Ability to Abstract

Describe:

Intelligence

Mental Retardation

Borderline

Average

Above Average

Estimate

IMPULSE CONTROL

Good

Poor

Absent

INSIGHT

Good

Poor

Absent

JUDGMENT

Good

Poor

Absent

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BIOPSYCHOSOCIAL ASSESSMENT

RISK ASSESSMENT

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	Abuse or Family Violence			Yes	No
Psychotic or Severely Psychologically Disabled			Yes	No
Is there a handgun in the home? Yes		No	Any other weapons?		Yes	No
Plan:
Safety Plan Reviewed	Yes	No

Diagnoses and Interpretive Summary

Biopsychosocial formulation

DSM IV-TR Provisional Diagnoses

Axis I

Axis II

Axis III

Axis IV

Axis V

Treatment Acceptance/Resistance

Client accepts problem?	No	Yes		Comment:
Client recognizes need for treatment?			No	Yes	Comment:
Client minimizes or blames others?			No	Yes	Comment:
External motivation is primary?		No		Yes Comment:
Strengths/Resources (enter score if present)				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			Other:
Comments:

Describe appropriateness & level of need for the family’s participation:

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BIOPSYCHOSOCIAL ASSESSMENT

Preliminary Treatment Plan & Referrals

Preliminary Biopsychosocial Treatment Plan

Biological:

Psychological:

Social/Environmental:

Referrals

Psychiatrist	Psychologist	Medical Provider		Spiritual Counselor
Benefits Coordinator	Nutritionist	Rehabilitation		Vocational Counselor
Social Worker	Community Agency:		Other:

Physical Fitness (Optional)

Physical Activity (please select one of the following based on activity level for the past month):

Avoids walking or exertion, e.g. always uses elevator, drives whenever possible instead of walking.

Walks for pleasure, routinely uses stairs, occasionally exercises sufficiently to cause heavy breathing or perspiration.

Participates regularly in recreation or work requiring modest physical activity such as golf, horseback riding, calisthenics, gymnastics, table tennis, bowling, weight lifting, and yard work.

10-60 minutes per week More than one hour per week

Participates regularly in heavy physical exercise, such as running, jogging, swimming, cycling, rowing, skipping rope, running in place or engaging in vigorous aerobic activity such as tennis, basketball or handball.

Runs less than a mile a week or engages in other exercise for less than 30 minutes per week

Runs 1-5 miles per week or engages in other exercise for 30-60 minutes per week

Runs 5-10 miles per week or engages in other exercise for 1-3 hours per week Runs more than 10 miles per week or engages in other exercise for more than 3 hours per week

10 OF 10

REVISED 5/3/06

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