biopsychosocial assessment 5


Here are the instructions and the format for the Biopsychosocial Assessment:

The scenario is: A 17 years old teen just found out she’s pregnant, along with finding out she is HIV positive she decides to keep the baby.

MUST watch the interview linked below to assign in doing the assignment.

Biopsychosocial Assessment Outline

  1. Identifying Information
  2. Nature of Presenting Problem
  3. Family of Origin Information
  4. Medical History and lifestyle risk factors
  5. Relational History
  6. Current Living Situation
  7. Social Support
  8. Employment and Financial Information
  9. Recreation
  10. Spirituality and Religion
  11. Summary
  12. Assessment
  13. Recommendations (later with treatment plan)
  14. Signature and Date


Assessment Guidelines/Template

Areas of Assessment: Identifying Information:

Put this in an easy to read format: For example:

Name__________ Age________________ SS# ________________

Client name, age, ethnicity, gender, length of time in country if not born here, address, level of education, employment, social security number, and insurance information if appropriate.

Nature of Presenting Problem (Identified Issue): What is client’s concern? How long has this been a concern? What are the particular manifestations of the concern? How intense are the manifestations of the concern? How often is this a concern? What has client already tried to do to deal with this concern? What has worked or not worked? What does client think is the cause of this concern? Are others aware of this concern? Does it effect others? Have others commented on the concern? What does client want to happen as regards the concern? Why is client coming for professional help at this time? How long does client think it will take to address the concern or how long are they willing to give toward working on the concern? What is client’s motivation to work on area of concern? What is the level of support in client’s life for his or her changing?

Developmental History: (generally children/adolescents only) Prenatal and birth history, developmental milestones, abuse issues, any traumatic events, health issues, psychological evaluations, mental /emotional development, social relations, school adjustment, sexual history (if appropriate).

Family of Origin Information: Where did client grow up? Does the client consider her/himself part of a cultural or ethnic group deriving from family of origin? When did client leave home? Does client have siblings? How close is client to siblings today? How often seen/ spoken to? Are parents alive? Where do they live? Divorced? Remarried? If so, when and how old was client? How close to parents today? How often seen/ spoken to? Parents employment when client was child? What was financial status of family when client was a child? Did family move a lot when client was a child? What were family values and traditions? What discipline methods did parents use? Who was the primary disciplinarian? What did family do for fun? Did family attend church? Together? Good memories of childhood. Bad memories of childhood. Was there extended family in client’s life as a child? More about that… Family health history, mental health history, and substance abuse history…

Medical History and Lifestyle Risk Factors: Does client have any acute or chronic health concerns? Is client currently taking any medications? Name medications. Currently under a doctor’s care? If so, who and how long? How long since last physical? What is general health of client? Nutrition/ diet? Is client underweight? overweight, mildly, moderately, or grossly? Does client smoke and how much? What is alcohol intake? Regular physical exercise or physical activity? Has client ever been hospitalized as a child or adult? Has client ever sustained any injuries? Has client ever been under psychiatric care? If so, what was diagnosis and treatment? Has client ever sought counseling before? What were the results of prior counseling? Has client ever had a problem with substance abuse? Any current distressing physical symptoms?

Sexual/ Relational Information: (if and when appropriate) What is client’s sexual orientation? Current marital status? Is client currently in a serious relationship? How happy in relationship? Any concerns? If not in relationship, is client dating? How many relationships has client had? How long have they lasted? Has client ever felt that he/she was raped, sexually abused in any way? At what age did client become sexually aware and active? Has client ever had any sexual concerns? Are there any concerns presently? Has client had any STD’s? Are there currently any untreated STD’s? How sexually active is client presently?

Living Situation: Where does client live? How long there? Where else has client lived since leaving home? Is client comfortable with current living situation? Who lives with client? How are these relationships? Is client living in a safe environment/ neighborhood? Does client wish to move or change living situation in some way?

Social Support: Does client have a social circle? Does client have a best friend? How long have these relationships been in client’s life? How satisfied is client with present relationships? Does client feel loved, respected, and nurtured? Does client offer support to others? Does church or spiritual tradition offer support? Does the cultural group to which he/she belongs (if this is true) offer support, create conflict, expose the client to discrimination?

Employment and Financial Information: Where does client currently work? What is position? How does client feel about this job? What is relationship with boss? What is relationship with co-workers? Any plans to leave this job? Any job concerns? Where else has client worked in the past? What were those jobs like? What were the reasons for leaving them? What job has client liked the best? What is client’s fantasy job? What is current financial status? Is client able to pay bills? Is client overloaded with debt? Does client feel stressed about money? Does client overspend for their current salary? Is client underemployed? Underpaid? Does client have to work more than one job? Is there any need or plans for further education?

Recreation: What does client do for fun, relaxation and how often? Does client have any hobbies? Are these solo or with others? Any sports or arts activities? Does client feel a need for more fun and relaxation? Does client seek time alone at times? Is there a balance of alone time and social time?

Spirituality/ Religion: Does client follow any particular spiritual or religious path? Does client go to some religious institution regularly? Does the client’s faith provide support? Is client happy with current level of spiritual involvement? Does client have any spiritual or religious concerns?

Assessment Statement: Summarize the most relevant points of sections above, restating reason for referral, background information, strengths and client goals. Provide your viewpoint of the person’s functioning in regard to the presenting problem.

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