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	template for a biopsychosocial assessment, pdffiller biopsychosocial, template biopsychosocial assessment, get the social work biopsychosocial assessment tool form

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:

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

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

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

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:

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

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:

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:

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

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:

Risk to Self	Low	Medium	High	Chronic
Risk to Others	Low	Medium	High	Chronic

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

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:

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