Navigating the pathway to recovery from chemical dependency involves various critical steps, one of which is completing the Intensive Outpatient Program Biopsychosocial Assessment, commonly referred to as form 224-008B. This comprehensive form serves as a foundational tool for clinicians at Chemical Dependency Centers to develop a personalized treatment plan tailored to the unique needs of each patient. It encompasses a wide array of questions designed to shed light on the patient's substance use history, motivation for change, and the various biopsychosocial factors that may impact their journey to recovery. By gathering detailed information about the patient’s prior treatments, mental health issues, substance use patterns, and the consequences of their use, the assessment aims to provide a holistic view of the patient's situation. Additionally, it delves into the patient’s environment and home life, vocational and educational history, legal and financial status, as well as their physical health, setting the stage for a treatment plan that addresses all aspects of their well-being. Importantly, the assessment is not just a formality; it is a critical engagement tool that helps establish a therapeutic relationship between the patient and their counselor, making it a pivotal first step in the intensive outpatient program.
| Question | Answer |
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| Form Name | Form 224 008B |
| Form Length | 5 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min 15 sec |
| Other names | 224 008 online biopsychosocial assessment form |
Chemical Dependency Center
INTENSIVE OUTPATIENT PROGRAM |
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BIOPSYCHOSOCIAL ASSESSMENT |
PATIENT LABEL |
Please complete this questionnaire and give it to your counselor on your first visit. This information will help your clinician gain an understanding of the problems for which you are seeking help and of other important events in your life.
YOUR NAME IN FULL |
AGE |
DATE OF BIRTH |
MEDICAL RECORD NUMBER |
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WHO REFERRED YOU TO LAUREATE? |
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TODAY’S DATE |
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MOTIVATION FOR CHANGE
WHAT FACTOR(S) LED YOU TO SEEK CHEMICAL DEPENDENCY TREATMENT AT THIS TIME? |
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EXPLAIN |
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Legal problems |
Health problems |
Financial problems |
Other - |
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Relationship problems |
School problems |
Work problems |
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PREVIOUS TREATMENT |
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TELL US ABOUT YOUR PREVIOUS MENTAL HEALTH OR SUBSTANCE ABUSE TREATMENT |
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DATE OF |
SUBSTANCE |
MENTAL |
NAME OF TREATMENT |
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TYPE OF TREATMENT |
RESPONSE TO TREATMENT |
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TREATMENT |
ABUSE |
HEALTH |
PROVIDER OR CENTER |
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(Residential, Detox, Outpatient, etc.) |
(How long did you stay sober?) |
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WHILE USING ALCOHOL OR DRUGS, HAVE YOU EXPERIENCED ANY OF THE FOLLOWING MENTAL HEALTH OR BEHAVIORAL PROBLEMS?
Depression |
Anxiety |
Compulsive gambling |
Compulsive sex or pornography |
Drug dealing |
Eating disorder |
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SUBSTANCE USE HISTORY |
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PATTERN OF USE (How much, how often) |
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AGE |
DATE |
CURRENT CRAVING |
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SUBSTANCES |
FIRST |
LAST |
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INTENSITY |
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PREVIOUS PATTERN |
CURRENT PATTERN |
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USED |
USED |
(None, moderate or strong) |
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FREQUENCY AND |
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FREQUENCY AND |
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QUANTITY |
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QUANTITY |
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ALCOHOL |
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(including beer and wine) |
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DEPRESSANTS |
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(Valium, Xanax, etc.) |
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STIMULANTS |
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(Speed, Meth, etc.) |
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COCAINE |
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(Powder, Crack, etc.) |
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MARIJUANA |
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(Any form) |
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HALLUCINOGENS |
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(Acid, Mushrooms, Ecstasy) |
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INHALANTS |
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(Poppers, paint, glue, etc.) |
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OPIATES |
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(Pain meds, heroin, etc.) |
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NICOTINE |
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(Smoked, smokeless, etc.) |
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*IN10 BIOPSYCHOSOCIAL ASSESSMENT*
*IN10 BIOPSYCHOSOCIAL ASSESSMENT*
Chemical Dependency Center
INTENSIVE OUTPATIENT PROGRAM |
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BIOPSYCHOSOCIAL ASSESSMENT |
PATIENT LABEL |
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YOUR NAME IN FULL |
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AGE |
DATE OF BIRTH |
MEDICAL RECORD NUMBER |
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CONSEQUENCES OF SUBSTANCE USE |
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Have you ever had work or school problems related to alcohol or drug use? |
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Yes |
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No |
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Has alcohol or drug use ever had a negative impact on any of your relationships? |
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Yes |
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No |
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Have you ever had legal charges related to your alcohol or drug use? |
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Yes |
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No |
Has alcohol or drug use ever led to any medical conditions? |
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Yes |
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No |
Has alcohol or drug use ever caused you any financial problems? |
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Yes |
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No |
OBSTACLES TO RECOVERY |
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DO YOU BELIEVE ANY OF THE FOLLOWING WILL MAKE IT MORE DIFFICULT FOR YOU TO STOP USING ALCOHOL OR DRUGS? |
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Living with someone who uses alcohol or drugs |
Having friends who use alcohol or drugs |
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Experiencing a great deal of job stress |
Being depressed or anxious |
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Having strong cravings for alcohol or drugs |
Having few or no hobbies or interests |
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DO YOU HAVE ANY COMMUNICATION DIFFICULTIES WHICH COULD AFFECT YOUR RECOVERY EFFORT (IE SPEECH, VISUAL, OR HEARING IMPAIRMENTS)? IF SO - WHAT?
DURING TREATMENT, WHAT SUPPORT SYSTEMS (FAMILY, FRIENDS, NEIGHBORS, CHURCH, ETC.) WILL BE AVAILABLE TO HELP YOU WITH YOUR SUBSTANCE ABUSE PROBLEM?
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CHILDHOOD DEVELOPMENTAL HISTORY |
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PROBLEMS EXPERIENCED DURING |
CHECK ONE |
IF YES - DESCRIBE |
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CHILDHOOD OR ADOLESCENCE |
YES NO |
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Delayed speech
Delayed motor development
Excessive shyness
Excessive aggression
Hyperactivity
Learning problems
Poor peer relationships
Alcohol or drug abuse
Depression
School failure / dropout
Runaway behavior
Illegal activities
Sexual abuse
Physical abuse
Abusing someone sexually
Abusing someone physically
FAMILY HISTORY
LIST ANY FAMILY MEMBERS BELOW WHO HAVE BEEN TREATED FOR MENTAL HEALTH OR SUBSTANCE ABUSE PROBLEMS
FAMILY MEMBER |
TYPE OF PROBLEM OR DISORDER |
TYPE OF TREATMENT |
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(Parents, grandparents, siblings) |
(Hospitalization, medication, etc.) |
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DESCRIBE ANY SIGNIFICANT CHILDHOOD EVENTS THAT YOU THINK MIGHT BE IMPORTANT TO UNDERSTAND YOUR CURRENT PROBLEM
Chemical Dependency Center
INTENSIVE OUTPATIENT PROGRAM |
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BIOPSYCHOSOCIAL ASSESSMENT |
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PATIENT LABEL |
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YOUR NAME IN FULL |
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AGE |
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DATE OF BIRTH |
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MEDICAL RECORD NUMBER |
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ENVIRONMENT AND HOME |
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MARITAL STATUS |
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SEXUAL ORIENTATION |
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WHO LIVES IN YOUR HOME WITH YOU? |
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Single |
Married |
Living as married |
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Divorced |
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LIST NAMES OF YOUR CHILDREN |
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WHO HAS CUSTODY? |
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WHAT CHILDCARE ARRANGEMENTS DO YOU HAVE? |
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HOW MANY CLOSE FRIENDS DO YOU HAVE? |
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ARE YOU SATISFIED WITH THIS NUMBER? |
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HAS THERE BEEN VIOLENCE / PHYSICAL / SEXUAL ABUSE IN YOUR CURRENT RELATIONSHIPS? |
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YOUR PAST RELATIONSHIPS? |
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Yes |
No |
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Yes |
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No |
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IF THERE IS SIGNIFICANT INFORMATION REGARDING YOUR SEXUAL HISTORY - LIST HERE |
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VOCATIONAL, EDUCATIONAL AND MILITARY HISTORY |
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WHERE ARE YOU EMPLOYED? |
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JOB TITLE |
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DO YOU LIKE YOUR JOB? |
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Yes |
No |
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HAVE YOU BEEN IN THE MILITARY? |
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IF YES - BRANCH |
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HIGHEST RANK |
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TYPE OF DISCHARGE |
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No |
Yes - |
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HIGHEST LEVEL OF EDUCATION |
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Did not complete high school |
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Completed college |
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Technical training |
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Obtained GED |
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Completed high school |
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Completed graduate school |
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RELIGION AND SPIRITUAL ORIENTATION |
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IS SPIRITUALITY A SIGNIFICANT PART OF YOUR LIFE? |
WHAT DENOMINATION ARE YOU AFFILIATED WITH - IF ANY |
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DO YOU ATTEND REGULARLY? |
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No |
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Yes |
No |
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WHAT GIVES YOUR LIFE MEANING? |
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FINANCIAL AND LEGAL STATUS |
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CURRENT LEGAL PROBLEMS - DESCRIBE |
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PAST LEGAL CHARGES - DESCRIBE |
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CURRENT FINANCIAL PROBLEMS - DESCRIBE |
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LEISURE AND RECREATION |
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LIST ANY INTERESTS OR HOBBIES |
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WHAT SOCIAL ACTIVITIES DO YOU PARTICIPATE IN? |
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ETHNIC AND CULTURAL INFORMATION |
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WHAT IS YOUR ETHNIC GROUP? |
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African American |
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Asian |
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Hispanic |
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Native American |
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Caucasian |
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Other - |
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WHAT, IF ANY, CULTURAL BELIEFS DO YOU HAVE THAT COULD BE RELEVANT TO YOUR TREATMENT?
WHAT ARE YOUR STRENGTHS, SUCH AS TALENTS, SKILLS OR PERSONAL CHARACTERISTICS?
*IN10 BIOPSYCHOSOCIAL ASSESSMENT*
Chemical Dependency Center
INTENSIVE OUTPATIENT PROGRAM |
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BIOPSYCHOSOCIAL ASSESSMENT |
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PATIENT LABEL |
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YOUR NAME IN FULL |
AGE |
DATE OF BIRTH |
MEDICAL RECORD NUMBER |
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*IN10 BIOPSYCHOSOCIAL ASSESSMENT*
BIOMEDICAL SCREENING
WHO IS YOUR PRIMARY CARE PHYSICIAN? |
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LIST YOUR PSYCHIATRIST - IF ANY |
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DESCRIBE ANY CHRONIC PAIN YOU MAY EXPERIENCE |
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CHECK ANY OF THE MEDICAL CONDITIONS BELOW WHICH YOU HAVE HAD |
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Chronic headaches |
HIV / AIDS |
GYN problems |
Blood disorder |
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Chronic stomach pains |
High blood pressure |
Weight gain |
Tuberculosis |
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Numbness |
Chest pain |
Blackouts |
Hepatitis |
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Eye disease |
Bronchitis |
Heart problems |
Venereal disease |
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Erectile dysfunction |
Hearing loss |
Cirrhosis |
Weight loss |
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HOW LIKELY IS IT THAT ANY OF THE ABOVE ARE RELATED TO YOUR ALCOHOL OR DRUG USE? |
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WHICH OF THE FOLLOWING OCCUR WHEN YOU DISCONTINUE USING ALCOHOL OR DRUGS - CHECK ALL THAT APPLY |
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Depressed mood |
Racing pulse |
Extreme anxiety |
Dilated pupils |
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Nausea or vomiting |
Insomnia |
Seizures |
Diarrhea |
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Sweating |
Hallucinations |
Fever |
Hand tremors |
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GOALS FOR TREATMENT
PLEASE INDICATE WHICH ONE OF THE FOLLOWING MOST APPLIES TO YOU AT THIS TIME
I think that total abstinence from alcohol and drugs is the only answer for me, and I want to stop drinking and using completely.
I think that total abstinence from alcohol and drugs may be necessary for me, but I am not sure. If I knew that controlled drinking and using were impossible for me, then I would want to stop drinking and using completely.
I think that total abstinence is not necessary for me, but I would like to reduce my drinking and using to a “light social”
I think that total abstinence is not necessary for me, but I would like to reduce my drinking and using to a “moderate social”
I think that total abstinence is not necessary for me, but I would like to reduce my drinking and using to a “heavy social”
I think that total abstinence is not necessary for me, and I see no need to reduce my drinking and using.
IS THERE ANY OTHER INFORMATION THAT YOU WANT STAFF MEMBERS TO KNOW ABOUT YOU?
HAVE YOU EVER ATTEMPTED SUICIDE?
Yes |
No |
DO YOU CONSIDER YOURSELF A HIGH RISK TO ATTEMPT SUICIDE IN THE FUTURE?
Yes |
No |
DO YOU CONSIDER YOURSELF OR ANY FAMILY MEMBER A SERIOUS THREAT TO DO HARM OR BE HARMED BY SOMEONE?
Yes
No
Chemical Dependency Center
INTENSIVE OUTPATIENT PROGRAM |
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BIOPSYCHOSOCIAL ASSESSMENT |
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PATIENT LABEL |
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YOUR NAME IN FULL |
AGE |
DATE OF BIRTH |
MEDICAL RECORD NUMBER |
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FOR STAFF USE ONLY BELOW THIS LINE
PATIENT HAS BEEN INFORMED OF THE NEED AND BENEFIT OF FAMILY OR SIGNIFICANT OTHERS PARTICIPATION IN WEEKLY FAMILY GROUP?
Yes
IF APPLICABLE, PATIENT MADE AWARE OF THE POSSIBLE RELATIONSHIP BETWEEN PATTERN OF SUBSTANCE USE AND IDENTIFIED MEDICAL CONDITIONS
Yes
IF APPLICABLE, PATIENT INFORMED OF NEED FOR PHYSICAL EXAMINATION
Yes
LEVEL OF CARE RECOMMENDATION |
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OUTPATIENT |
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No withdrawal risk |
Cooperative but needs motivation |
No biomedical complications |
Needs minimal support for abstinence |
No emotional / behavioral complications |
Supportive recovery environment |
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INTENSIVE OUTPATIENT |
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Minimal risk of severe withdrawal |
Resistance moderate but requires structured program |
No or manageable biomedical conditions |
Likelihood of relapse without close monitoring and support |
Mild emotional / behavioral conditions requiring monitoring |
Environment is |
INPATIENT
Severe withdrawal requiring medical monitoring
Requires inpatient diagnosis and treatment
Dual diagnosis requires
TREATMENT ACCEPTANCE LEVEL
Withdrawal symptoms require medical treatment - referred to Inpatient
Some resistance, requires structured program - referred to Intensive Outpatient Program
Cooperative but needs motivating and monitoring strategies - referred to Outpatient
ADDITIONAL STAFF COMMENTS - IF APPLICABLE
*IN10 BIOPSYCHOSOCIAL ASSESSMENT*
REVIEWED BY - PRINT
CLINICIAN’S SIGNATURE
CREDENTIALS
DATE