Biopsychological Assessment

Client Name: ______¬¬¬¬ Date of Assessment:

I. PROBLEM IDENTIFICATION

PRESENTING PROBLEM and PRECIPITATING EVENTS:

1. What has brought you to counseling? What have you been feeling and experiencing (symptoms)?
2. How long have you been experiencing these symptoms?
3. How often do you experience these symptoms?
4. How does it impact your SOAR Functioning (Social/Friends Relationships, Occupation, School, and Family Relationships)?
5. What does counseling mean to you?
6. What do you hope to gain?
7. What are your expectations of counseling at the CARE Center?

TREATMENT HISTORY:

1. Have you ever been to counseling before?

If NO, please type Client reports no treatment history and move to next section

If YES,

1. When?
2. What was the level of care? (Outpatient/in a facility (residential) setting/hospital etc.).
3. What was that like for you? (i.e., What went well? What worked? What didn’t?)

II. FAMILY/SOCIAL/CHILDHOOD HISTORY

FAMILY OF ORIGIN:

1. Where were you raised and by whom? What was growing up like for you?
2. Do you have any siblings?
3. What was growing up like in your household?
4. Describe interactions with all family members, immediate, cousins, nephews, etc.
5. Is there any family history (immediate family) of substance use, criminal involvement, mental health issues?

If YES, elaborate:

FAMILY OF CHOICE:

1. Are you or have you ever been married? If yes, provide time length and status.
2. Are you involved in a significant relationship? If yes, are you satisfied with relationship with partner(s)?
3. Do you have any children? If yes, are you satisfied with the relationship with your children?
4. Is there any history (with partner (s) and/or children) of substance use, criminal involvement, mental health issues?

If YES, elaborate:

HOUSING AND FINANCIAL INFORMATION:

1. What is your current living conditions and environment?
2. Do you feel this is conducive to your progress in counseling? Why or why not?
3. How would you describe your current financial situation?

SUPPORT SYSTEMS:

1. Do you have an existing positive support system? Describe.
2. To whom do you feel closest and why?
3. Describe some of your relationships (including pets).
4. Who do you spend the most time with (peer support)?

OCCUPATIONAL INFORMATION:

1. Have you ever been employed?
   If YES, provide brief description of current or last job and time length.
2. Do you have any employment goals? What are they?
3. Have you ever served in the military? If yes, when?

EDUCATIONAL INFORMATION:

1. What is the highest grade level you completed?
2. Do you have any vocational training?
3. Are you currently enrolled in and attending school?
4. Do you have any further educational goals?

MULTICULTURAL INFORMATION:

CULTURAL INFLUENCE

1. Were you raised in any specific culture?
2. Do you currently identify with any specific cultural group?

RELIGION/SPIRITUALITY

1. Is religion or spirituality important in your life?
2. How do you express your spirituality?
3. Who or what provides you with strength and hope?

IDENTITIES

1. Describe your affectional identity (you may know this as sexual identity or orientation).
2. Describe your gender identity.

DEVELOPMENTAL/CHILDHOOD HISTORY

1. Describe any issues during birth, pregnancy, infancy, childhood
2. Describe any developmental milestones (ages) and challenges (walking, talking, crawling etc.)

III. TRAUMA HISTORY:

History of Trauma: • YES • NO

Trauma Type Explain Details of Report (if minor, elder, or vulnerable person, date of report, specify which authorities it was reported to, outcome of report)

• Emotional Abuse
• Physical Abuse
• Physical Neglect
• Sexual Abuse/Molestation
• Rape/Sexual Assault
• Domestic/Intimate Partner Violence
• Elder Abuse
• School Violence
• Community Violence
• Family Trauma

IV. MEDICAL/PHYSICAL/PSYCHIATRIC HISTORY:

DATE OF LAST PHYSICAL EXAM:

PAST/CURRENT MEDICAL ISSUES

1. Describe significant injures, diseases/illnesses, allergies (age, outcome)
2. Describe medical hospitalizations and surgeries
3. Describe your past and current sleep pattern (how many hours, interrupted sleep, nightmares, flashbacks)
4. Describe your past and current nutritional pattern (Do you eat 3 meals a day, do you have a special diet, eating problems or behaviors):

CURRENT MEDICATIONS (Include Vitamins, supplemental sources):

Name of Medication For Whom Was It Prescribed For: Prescribed By (Type of Doctor): Reason for Taking Medication Amount/Frequency Duration Side Effects

• Self 

• Other (please describe): • Self
• Other (please describe):

PAST/CURRENT EMOTIONAL/MENTAL HEALTH DIAGNOSES (when did you receive the diagnosis and by whom)

V. SUBSTANCE USE/ADDICTIVE BEHAVIOR HISTORY

SUBSTANCE USE INFORMATION: • YES • NO

Type Use Age Of First Use Amount/Frequency Method Date/Age of Last Use Pattern of Use (episodic, experimental, binge, continued, mental/behavioral)
•Alcohol •Past • Present •N/A

• Marijuana or Hashish •Past •Present •N/A
• Cocaine •Past •Present •N/A
• Crack Cocaine •Past •Present •N/A
• Ecstasy •Past •Present •N/A
• Hallucinogens (Mushrooms, Acid) •Past •Present •N/A
• Prescription: •Past •Present •N/A
• Heroin •Past •Present •N/A
• Crystal Methamphetamine •Past •Present •N/A
• Methadone •Past •Present •N/A
• Caffeine •Past • Present •N/A
• Nicotine/Cigarettes (Electric Cigarettes, Nicotine Patches) •Past • Present •N/A
• Inhalants (e.g., glue, gas) •Past •Present •N/A
  •Opiates •Past Present •N/A
• Ketamine, GHB) •Past •Present •N/A
• Other: •Past •Present •N/A

ADDICTIVE BEHAVIOR INFORMATION: • YES • NO

Type Use Age Of Onset Amount/Frequency Date/Age of Last Use

• Gambling •Past •Present •N/A
• Sexual •Past •Present •N/A
• Internet •Past •Present •N/A
• Food (specifically ask about eating disorders and/or disordered eating) •Past •Present •N/A
• Shopping •Past •Present •N/A
• Other: •Past •Present •N/A

If any of these areas are identified, are they something you would like to address in counseling?

Past or Current Treatment for Addiction or Substance Use:

If NO, type Client reports no treatment history and move to the next section

If YES,

1. When?
2. What was the level of care? (Residential, outpatient, hospital, support groups, MarchMan Act etc.).
3. How long?
4. What was that like for you? (i.e., What went well? What worked? What didn’t?)

VI. LEGAL HISTORY

LEGAL INFORMATION

1. Do you have any past or current history in the Criminal Justice system? Incarcerations? Probation? Family Court? If NO, type Client did not report any past or current history legal history and move to the next section

If YES, please document each instance. (Include dates and reason)

2. Are these legal matters current and will they influence progress in treatment?
3. How do they affect you at the present time?

VII. MOTIVATION FOR CARE

STRENGTHS

1. What are some of your hobbies? How do you disconnect?
2. What are some of your strengths?
3. What are areas that you might like to work on?
4. What is your motivation for treatment at this time?

V. MENTAL STATUS EXAM

General Observations
Appearance • Well-groomed • Unkempt • Disheveled • Malodorous
Build •Average • Thin • Overweight • Obese
Attitude • Average • Preoccupied • Hostile • Withdrawn • Guarded • Demanding
Eye Contact • Average • Avoidant • Intense
Psychomotor Activity • Normal • Agitation • Wringing of Hands

• Pacing • Restlessness • Slow body Movements
  Speech •Clear • Slurred • Rapid • Pressured
  Thought Content
  Delusions • None Reported • Grandiose • Persecutory • Somatic • Religious • Paranoia
  Describe:

Other • None Reported • Obsessions • Compulsions • Phobias • Poverty of Content

• Anhedonia • Ideas of Reference • Thought Broadcasting
  Describe:

Suicidal
• None Reported • Ideation History • Previous Attempts

• Current Ideation • Viable Plan • Available Means
  Comments:

Homicidal • None Reported • Previous Intimidation • History of Violence

• Current Intent • Viable Plan • Available Means
  Comments:

Self-Abuse • None Reported • Self-mutilation (Cutting, burning, etc.)
Perception
Hallucinations •None Reported • Auditory • Visual • Olfactory • Gustatory • Tactile
Describe:

Other • None Reported • Illusions • Depersonalization • Derealization
Thought Process

• Logical •Goal-Oriented • Circumstantial • Tangential • Loose Associations
• Incoherent • Concrete • Flight of Ideas • Ruminative • Racing Thoughts
  Describe:

Mood

• Euthymic • Depressed • Anxious • Angry • Euphoric • Irritable
• Guilty • Dysthymic • Hopelessness • Helplessness • Frightened • Other: specify:_
  Affect
• Within Normal Range • Euthymic • Constricted • Flat • Labile • Congruent with Mood
  Behavior
• Cooperative • Assaultive • Anhedonia • Resistant • Aggressive • Withdrawn
• Agitated • Hyperactive • Guarded • Impulsive • Restless • Hostile
  Cognition
  Orientation •Person • Place •Time • Event
  Memory Impairment •None • Short Term • Long Term
  Attention/Concentration • Normal • Easily Distracted
  Judgment • Good •Fair • Poor
  Comments:
  Insight • Good • Fair • Poor
  Comments:

VI. DIAGNOSTIC INFORMATION

Name of Diagnosis (include specifiers) 

VII. CLINICAL IMPRESSION

INITIAL CLINICAL IMPRESSION (General Initial Assessment of Client, Identification of Client’s Strengths and Barriers to Treatment (Individual, Family, Peer, School/Work, Community), Identification of Main Concerns and Specific Areas for Possible Intervention):

__________________ _____ __
Clinician’s Name (Credentials and Title) Clinician’s Signature: Date

Signature Below Indicates that I have Reviewed and Approved the Assessment:

_________________________ _____________ _
Clinical Supervisor Name (Credentials and Title) Clinical Supervisor’s Signature Date