Biopsychosocial Assessment Format2
Biopsychosocial Assessment Format2
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