Biopsychosocial Assessment
Comprehensive clinical assessment for mental health evaluation and treatment planning
Biological History
Medical History (including current and past medical conditions, medications, allergies)
Family History (medical, psychiatric, substance use)
Psychological History
Previous Mental Health Diagnoses and Treatments
Trauma History
Describe any history of trauma or significant life events
Social History
Current Living Situation
Relationship Status and Social Supports
Employment and Education History
Substance Use History
Describe substance use (type, frequency, duration, last use)
Current Symptoms
Describe current symptoms and concerns
Risk Assessment
Are there current thoughts of suicide?
*
Yes
No
Are there current thoughts of harming others?
*
Yes
No
Are there current thoughts or behaviors of self-harm (non-suicidal)?
*
Yes
No
Please provide details if any risk is present (suicide, homicide, self-harm)
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Mental Status
How would you describe your current mood?
How would you describe your current Thought Process?
How would you describe Cognition, Insight, and Judgment at this time?
Have you previously been given any Mental Health Diagnosis?
Primary Diagnosis
Secondary Diagnosis (if applicable)
Treatment Plan
Describe treatment goals you want to work on?
Client Signature
*
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.
Format: (000) 000-0000.
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