Biopsychosocial Assessment Form
Client Information
Client Name
Mr.
Mrs.
Miss.
Prefix
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Age
Email Address
example@example.com
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Presenting Problem
Please describe your problem.
How long have you been facing this problem?
Less than a month
1-6 months
1-5 years
More than 5 years
How intense is this problem?
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
How does this problem effects your daily life?
What do you expect from your therapy sessions?
Please select the symptoms that you experienced in the last 30 days?
Sadness
No motivation
Not hungry
No need for sleep
Hopeless/Helpless
Lack of interest
Sleep too much
Hearing things
Fearful
Implusive
Can't sleep
Panic attacks
Feel wothless
Guilt
Other
Have you ever contemplated suicide?
Yes
No
N/A
Have you ever had a trauma?
Yes
No
N/A
Are you pregnant now?
Yes
No
N/A
Are you at risk for HIV/AIDS?
Yes
No
N/A
Do you smoke any forms of tobacco?
Yes
No
N/A
Please give details.
Are you having any problems with alcohol?
Yes
No
N/A
Please give details.
Are you having any problems with pills or illegal drugs?
Yes
No
N/A
Please give details.
Who is in your family?
How are the relationships in your family?
Good
Fair
Poor
Close
Stressful
Distant
Other
Are there any of the following problems in your family?
Conflict
Abuse
Stress
Loss
Divorce
Leave
Other
What is your marital status now?
Single
Married
Living as Married
Divorced
Widowed
Never Married
What is your highest level of education?
No education
High school diploma
Graduate school
College degree
Masters degree
Other
Have you ever been arrested?
Yes
No
N/A
Please give details.
What is your current employment status?
Full time employed
Part time employed
Seasonal worker
Unemployed looking for a job
Unemployed not looking for a job
Other
Past and current medical/surgical problems.
Please list any allergies or medications.
Anything you would like me to know about you.
Submit
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