Biopsychosocial History/Intake Assessment
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Please List Your Presenting Problems and How Long You've Had Them.
*
What Do You Consider Your Strengths?
*
What Do You Consider Your Weaknesses?
*
What Are Your Present Traumas?
*
What Are Your Past Traumas?
*
Current Symptom Checklist
*
Mild
Moderate
Severe
Depressed Mood
Significant Weight Loss/Gain
Grief
Guilt
Emotional Trauma Victim
Sleep Disturbance
Physical Trauma Victim
Mental Status Exam
*
Good
Fair
Easily Distracted
Highly Distractible
Attention
*
Appropriate
Easily Altered
Expansive
Constricted
Blunted
Emotions
*
Normal
Depressed
Anxious
Euphoric
Mood
*
Well-groomed
Disheveled
Bizarre
Inappropriate
Appearance
*
Calm
Hyperactive
Agitated
Tremors
Tics
Muscle Spasms
Motor Activity
*
Intact
Disorganized
Disturbance
Rapid Ideas
Lack of Connection
Thought Process
*
None
Auditory
Visual
Olfactory
Command
Hallucinations
*
None
Persecutory
Grandiose
Religious
Other
Delusions
*
Intact
Impaired: Immediate
Impaired: Recent
Impaired: Remote
Memory
*
Intact
Impaired: Mild
Impaired: Moderate
Impaired: Severe
Judgement/Insight
*
All Spheres
Impaired: Person
Impaired: Place
Impaired: Time
Impaired: Purpose
Awareness of Self
*
None
Ideation
Plan
Intent
Means
Suicidal
*
None
Ideation
Plan
Intent
Means
Homicidal
*
Normal
Slow
Slurred
Pressured
Rapid
Speech
Functional Impairment (Estimate the effect of behavioral problems or emotional distress on the following areas)
*
None
Mild
Moderate
Severe
Family
Relationship with S/O and Other Primary Relationships
Physical Health
Work
School
Spiritual/Sense of Meaning
Social/Activity Level
Emotional/Psychiatric History
*
Yes
No
Prior outpatient psychotherapy?
Has any family member had outpatient psychotherapy?
Prior inpatient treatment for a psychiatric, emotional, or substance use disorder?
Has any family member had inpatient treatment for a psychiatric, emotional, or substance use disorder?
If yes, to any of the above questions, please list the name of the person and why (please put "N/A" if it doesn't apply).
*
*
Yes
No
Prior or current medication usage?
If yes to medications usage, please list them, when started and/or ended, if there were in side effects, and name of physician.
*
Family History/Origin (What were you born and raised? Describe parents- full names, occupation, education, general health).
*
List any abnormal lab test results (dates, results, please put "N/A" if it doesn't apply).
*
Please indicate the following who were present during your childhood.
*
Present Entire Childhood
Present Part of Childhood
Not Present At All
Father
Mother
Siblings
List siblings name, age and gender (if this doesn't apply, please put "N/A").
*
*
Married
Divorced
Separated
Never Been Married
Marital Status
*
Yes
No
Currently in a Relationship?
*
Very Satisfied with Relationship
Satisfied with Relationship
Somewhat Satisfied with Relationship
Dissatisfied with Relationship
Very Dissatisfied with Relationship
N/A
Relationship Satisfaction
List all persons currently living in your household (name, age, gender, relationship, if this doesn't apply, please put "N/A").
*
Medical History
*
Good
Fair
Poor
Describe Current Physical Health
Please list name of Primary Care Physician and/or Psychiatrist (if this doesn't apply, please put "N/A").
*
Describe any serious hospitalizations or accidents (date, reasons, age, if this doesn't apply, please put "N/A).
*
Is there a history of any of the following in family?
*
Yes
No
Behavior Problems
Emotional Problems
*
Yes
No
Family Alcohol and/or Drug Abuse History
If yes to the question above, please list substances used, consequences of substance abuse, treatment history (if this doesn't apply, please put "N/A").
*
Socio-Economic History
*
Yes
No
Adequate Housing
Supportive Network
Employed
Are you Satisfied with Employment?
Military History
Legal Problems
Financial Issues
Cultural/Spiritual/Recreational History
Yes
No
Currently active in communities/recreation activities?
Cleanliness
Responsiveness
Friendliness
If yes to the above, please describe (if this doesn't apply, please put "N/A).
*
Cultural Identity (e.g. ethnicity, religion)
*
Submit
Should be Empty: