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Biopsychosocial Assessment Format2

This biopsychosocial assessment outlines the necessary information to be collected about a client, including their demographic details, history, mental status, diagnosis, and proposed treatment plan. Key areas of focus are the client's presenting problem, background, assessment of contributing factors from ecological and systems perspectives, strengths, and recommendations for short and long-term goals. The thorough assessment aims to understand the client holistically in the context of their environment to appropriately diagnose and treat their current difficulties.

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Hassan Maqsood
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2K views

Biopsychosocial Assessment Format2

This biopsychosocial assessment outlines the necessary information to be collected about a client, including their demographic details, history, mental status, diagnosis, and proposed treatment plan. Key areas of focus are the client's presenting problem, background, assessment of contributing factors from ecological and systems perspectives, strengths, and recommendations for short and long-term goals. The thorough assessment aims to understand the client holistically in the context of their environment to appropriately diagnose and treat their current difficulties.

Uploaded by

Hassan Maqsood
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Biopsychosocial Assessment

(ONLY THE FORMAT OF THIS DOCUMENT AND BOLDED TITLES SHOULD


BE WRITTEN INTO YOUR ASSESSMENT—THE REMAINING ITEMS ARE
CUES FOR WHAT INFORMATION IS TO BE CONSIDERED AND
COLLECTED DURING THE INTERVIEW PROCESS)

I. Identifying Information
A. Demographic information: age, sex, ethnic group, current employment, marital status,
physical environment/housing: nature of living circumstances (apartment, group
home or other shared living arrangement, homeless); neighborhood.
B. Referral information: (referral source (self or other), reason for referral. Other
professionals or indigenous helpers currently involved.
C. Data sources used in writing this assessment: interviews with others involved (list
dates and persons), tests performed, other data used.
II. Presenting Problem
A. Description of the problem, and situation for which help is sought as presented by the
client. Use the client’s words. What precipitated the current difficulty? What feelings
and thoughts have been aroused? How has the client coped so far?
B. Who else is involved in the problem? How are they involved? How do they view the
problem? How have they reacted? How have they contributed to the problem or
solution?
C. Past experiences related to current difficulty. Has something like this ever happened
before? If so, how was it handled then? What were the consequences?
III. Background History
A. Developmental history: from early life to present (if obtainable)
B. Family background: description of family of origin and current family. Extent of
support. Family perspective on client and client’s perspective on family. Family
communication patterns. Family’s influence on client and intergenerational factors.
C. Intimate relationship history
D. Educational and/or vocational training
E. Employment history
F. Military history (if applicable)
G. Use and abuse of alcohol or drugs, self and family
H. Medical history: birth information, illnesses, accidents, surgery, allergies, disabilities,
health problems in family, nutrition, exercise, sleep
I. Mental Health history: previous mental health problems and treatment,
hospitalizations, outcome of treatment, family mental health issues.
J. Nodal events: deaths of significant others, serious losses or traumas, significant life
achievements
K. Cultural background: race/ethnicity, primary language/other languages spoken,
significance of cultural identity, cultural strengths, experiences of discrimination or
oppression, migration experience and impact of migration on individual and family
life cycle.
L. Religion: denomination, church membership, extent of involvement, spiritual
perspective, special observances
IV. Assessment
A. What is the key issue or problem from the client’s perspective? From the worker’s
perspective?
B. How effectively is the client functioning?
C. What factors, including thoughts, behaviors, personality issues, environmental
circumstances, stressors, vulnerabilities, and needs seem to be contributing to the
problem(s)? Please use systems theory with the ecological perspective as a
framework when identifying these factors.
D. Formulate a risk and protective factors assessment, both for the onset of the disorder
and the course of the disorder, including the strengths that you see for this individual.
E. Identify the strengths, sources of meaning, coping ability, and resources to be
mobilized to help the client.
F. Assess client’s motivation and potential to benefit from intervention

V. Mental Status Assessment/Exam


1. Appearance
2. Behavior
3. Mood
4. Affect
5. Speech
6. Cognition
7. Thought Content
8. Thought Process
9. Perception
10. Judgement
11. Insight

VI. Summary Impression


Provide a brief written broad level overview of the first four segments of this assessment
along with your summary of what you believe to be the key themes (concerns, strengths,
presentation etc.).

VII. Diagnosis and Rationale


Given the case information, and your responses to the questions below, prepare the
following: a diagnosis, the rationale for the diagnosis order to make a more accurate
diagnosis
(Formulate a critique of the diagnosis as it relates to this case example. Questions to
consider including- Does this diagnosis represent a valid mental disorder from the social
work perspective? Is this diagnosis significantly different from other possible diagnoses?
Your critique should are based on the values of the social work profession (which are
incongruent in some ways with the medical model) and the validity of the specific
diagnostic criteria applied to this case.)

VIII. Recommendations/Proposed Intervention


(Given your risk and protective factors assessments of the individual, your knowledge of
the disorder, and evidence-based practice guidelines, formulate goals and a possible
treatment plan for this individual)

A. Tentative Goals (with measurable objectives and tasks)


1. One Short-term
2. One Long-term
B. Units of Attention
C. Possible obstacles and tentative approach to obstacles

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