Biopsychosocial Template Fillable Details

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.

QuestionAnswer
Form NameBiopsychosocial Template
Form Length10 pages
Fillable?Yes
Fillable fields1028
Avg. time to fill out34 min 41 sec
Other namesbiopsychosocial 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:

1 OF 10

REVISED 5/3/06

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:

2 OF 10

REVISED 5/3/06

BIOPSYCHOSOCIAL ASSESSMENT

Pain Questionnaire

Pain Management: Is the client in pain now?

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

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

No

 

 

 

 

 

 

 

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

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

No

 

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

 

 

No

Type of Discharge:

 

 

 

Honorable

 

 

Dishonorable

 

 

 

 

Medical

 

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

Sexual Orientation:

 

 

 

 

 

 

 

 

 

Heterosexual

 

 

 

 

 

 

 

 

Bisexual

 

 

 

 

 

 

 

 

 

 

 

 

 

Homosexual

 

 

 

 

 

 

 

 

Transgendered

 

 

 

 

 

 

 

 

 

N/A at this time

 

 

 

 

 

 

 

 

Comment:

 

 

 

 

 

 

 

 

 

 

 

 

 

3 OF 10

REVISED 5/3/06

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

No

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:

 

5 OF 10

REVISED 5/3/06

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:

6 OF 10

REVISED 5/3/06

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

No

 

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?

No

Yes, explain:

 

 

 

 

 

 

 

 

 

 

 

 

 

Has client been tested for HIV?

Yes

 

 

No

 

 

 

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:

 

 

 

 

 

 

 

 

 

 

 

7 OF 10

REVISED 5/3/06

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

8 OF 10

REVISED 5/3/06

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:

9 OF 10

REVISED 5/3/06

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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