Biopsychosocial Assessment

This document is used to gather important information about your life to provide a comprehensive framework for treatment.

Demographics

Client First Name

Client Last Name

Date

Address

house #, street name, suite/building #

City

State

Zip Code

Phone Number

Date of Birth

Age

Sex

Male Female

Do you speak and understand English?

Yes No

Do you speak another language?

Yes No

Please list the language(s).

What is your ethnicity?

African American/Black American Indian/Alaska Native Caucasian/White East Asian Hawaiian/Pacific Islander Hispanic Middle Eastern South Asian Biracial

General

Can I leave you voicemails?

Yes No

Can I send you emails?

Yes No

Emergency Contact: Name

Emergency Contact: Relation

Emergency Contact: Number

How did you hear about me, Serene Therapy?

Psychology Today

Google Search/Website

Provider/Doctor*

Friend/Family*

Lyra*

Other*

Please list the name of the individual(s).

Please list the name of the company sponsoring you (e.g. Starbucks).

Lyra Code: If you would like to use Lyra to pay for services, it is essential to include it; however, if your company did not provide one, you can type: n/a. Be sure to check, before submitting.

Please explain.

Reason for Treatment

Presenting Problem

What is the reason you are seeking treatment? What are the problem behaviors or issues you are having?

Precipitating Event

What led you to seek therapy, now? You may have needed help, previously, but did not get help; why now?

Goals for Treatment

Please list what your main goals are. What are you hoping to accomplish in therapy?

Goals for Treatment

Please list what your main goals are. What are you hoping to accomplish in therapy?

Goals for Treatment

Please list what your main goals are. What are you hoping to accomplish in therapy?

Medications & Substance Use

Please list medications you are taking and related information.

Include the name, dose, frequency, and purpose. e.g. Prozac 20mg 1 time daily for depression

Do you, currently, have issues with substance use?

Yes No

Please list the substances:

Did you have past issues with substance use?

Yes No

Please list the substances:

Risk and Safety

***If you, currently, have any suicidal ideation, plan, and/or intent, please call 911 and/or visit your nearest emergency room.

History: Have you, previously, had any suicidal ideation, plan, and/or intent?

Suicidal Ideation

Suicidal Plan

Suicidal Intent

No, I do not have any past suicidal ideation, plan, and/or intent.

Have you had any previous suicide attempts? If yes, please explain.

Include date, method, reason, result (e.g. hospitalization?).

Is there any family history of suicide? If yes, please explain.

Include family relation, method, and circumstances.

***If you, currently, self-harm, please seek help by calling 911 and/or going to your nearest emergency room.

History: Have you self-harmed in the past? If yes, please explain.

Include date, method, reason, result (e.g. medical care needed?).

***If you, currently, have any homicidal ideation, plan, and/or intent, please call 911 and/or visit your nearest emergency room.

History and Current Information

Do you have any issues with sleep? If so, please explain.

This can include sleeping too much, sleeping too little, hard time falling asleep, hard time staying asleep, nightmares, and incontinence.

Please list any current providers and/or relevant past treatments.

This can include therapists, psychiatrists, medical doctors, dietitians, as well as programs you have completed Detox, IP, RTC, PHP, and IOP.

Briefly describe any history of physical, sexual, emotional, or verbal abuse, or any significant trauma?

List all health problems.

This includes serious illnesses, hospitalizations, surgeries, head injuries, severe accidents and injuries, allergies, and other medical conditions.

Do you have any issues with completing Activities of Daily Living (ADLs)? If so, please explain.

This includes showering, brushing your teeth, changing your clothes, wearing clean clothes, etc. Include the reason why you are challenged (e.g. physical limitations, lack of motivation).

Do you have any issues with your food intake?

This includes an eating disorder, picky eating, selective eating, food allergies, medical complications (e.g. diabetes, delayed gastric emptying), etc.

What is your occupation? Include main job responsibilities.

Is there family history of mental health, emotional, behavioral, or substance use issues? If so, please explain.

Include diagnoses, problems, and your relationship to the person(s).

How do you get along with your family? This includes your family of origin (parents, siblings) and your chosen family (spouse, partner, children).

Who do you consider part of your support system?

This includes family, friends, close co-workers, treatment team, etc.

Where and with whom do you live?

Include type of housing (e.g. house, apartment) and inhabitants relation to you.

How do you identify?

Straight/Heterosexual Gay/Lesbian Bisexual Unsure Other

Please list.

Are you, currently, in a relationship? If so, please explain.

Include name, age, how long you have been in the relationship, and your satisfaction with the relationship.

Have you had any issues with previous relationships? If so, please explain.

Are you religious or spiritual?

Religious

Spiritual

Neither

Please list the name of your religion or spiritual practice.

Are you comfortable with your level of religiosity, spirituality, or lack thereof?

Yes No

Do you see your level of religiosity/spirituality affecting your treatment, whether positive or negative? If yes, please explain.

Do you have any legal concerns? If yes, please explain.

This includes court dates, recent arrests, warrants, etc.

Mood and General Symptoms

I attest that all information provided in this document is true.

Your information will be encrypted.