Biopsychosocial Client History Form

Biopsychosocial Client History Form

Please provide any information that you are comfortable sharing to help us understand your background and current concerns.
Client's Legal Name

PrefixFirst NameMiddle InitialLast NameSuffix
What is going on that you are seeking help now?
Include what are you experiencing or what stressors are you facing now that led you to seek out therapy services.
Describe if you have ever experienced similar or other mental health symptoms before.
Include type of symptoms and if anything had helped improve your mood or the situation.
Have you ever received mental health treatment, past or current?
If yes, please describe your mental health treatment history.
Include diagnosis or reason for treatment, and what type of treatment (therapy, peer support, medication management, inpatient or hospital stay, etc.).
Do you have any current or past medical conditions? If so, please describe.
Include any conditions impacting your blood pressure, heart, kidneys, or liver; or any diseases such as diabetes, high cholesterol, stroke, cancer, or gout.
Do you have any known allergies? If so, please list them.
Include prescription and over-the-counter medications, vitamins, food, environmental, or anything else.
Please list any current prescribed medications that you are taking for physical or mental health.
Have you used alcohol, tobacco, recreational drugs, or prescription medication other than prescribed?

Other
Please describe your use of any substances selected above (age of first use, frequency, duration, etc.).
Do you have any blood relatives with diagnosed or suspected mental health or substance use issues?
If yes, please specify which family members and the nature of their issues.
What spiritual and/or cultural influences are important to you?
Include how you celebrate culture and spirituality in your life; religious, faith, or spiritual community that you participate. Describe how your spiritual/cultural background feel about mental health in general or getting treatment.
Please describe any significant educational and/or work experiences you have had.
Include highest level of education you have completed and any volunteering or employment history. If currently in school or employed, what are typical stressors you face and how satisfied you are with your performance.
Please describe if you have had any current or past legal issues.
Include if you have ever been arrested or charged with a crime or misdemeanor. List if you have had any past or current involvement with the civil courts, such as a lawsuit, bankruptcy, or family law matter.
Please briefly describe your current living situation.
Include who lives with you, quality of relationships, and anything else significant.
Please describe if there is anything that stands out about your childhood or upbringing.
Include any changes in family dynamics like separations, trauma, and loss.
What else feels important for us to understand about you so we can provide the best care that meets your needs?
Include any goals that you would like to work towards.
Should be Empty: