Client: Date of Birth:Age: Sex: Race

Bio-Psychosocial Evaluation

Client Name:

Client: Date of Birth:Age: Sex: Race:

Primary Clinician: Intake Date:

PSYCHOSOCIAL STRESSORS(circle descriptors or, if typing, delete descriptors that do not apply)
Familychanges: divorce/remarriage, death/birth, estranged, caregiver changes, other:
Family conflict: between siblings, parent-child, couple/marital, extended family, other:
Social/Relationships: lack of friends, peer conflict/rejection, death/loss of friend, other:
Placement/Housing: crowded, moves, unsafe, homeless, risk of eviction/foreclosure, other:
Educational: school changes, academic delays, poor grades, discipline, other:
Financial/Work: low income, unemployed, supervisor conflict, retirement, other:
Legal: protective services, arrest, incarceration, probation, litigation, police called, other:
Disability/disorder: SSI, injury, chronic illness, physical limitation,developmental, other:
Trauma/abuse: sexual abuse, physical abuse, foster care, crime victim, natural disaster, other:
Current safety threat (written safety plan required):
Other stressor:
Describe:
MEDICAL/PHYSICAL HISTORY
Developmental history (children only): delays in crawling walking speech other:
Immunizations up-to-date (children only): yes no, explain:
Current & past medical issues (check all that apply & provide details below):
noneSeizure disorderHypertensionGross motor problem
HeadachesDiabetesHeart problemFine motor problem
Stomach achesHIV/AIDSKidney problemPrenatal drug exposure
Bowel problemBrain injuryThyroid problemLife-threatening illness***
AllergiesParaplegiaVision impairment ***(requires safety plan)
AsthmaDental problemHearing impairmentOther:
Details:
ADAPTIVE FUNCTIONING/STRENGTHS
Self care skills:age-appropriate, verbal prompting, physical assistance, dependent, other:
Communication level:age appropriate, articulation, nonverbal, speech delay, echoic, other:
Intellectual/developmental abilities:IQ low/average/high, Autism/ASD, learning disability, other:
Leisure/recreation interests:
Support network/current resources:
Client strengths:
Family strengths:
Other strengths:
EDUCATIONAL HISTORY
Highest grade completed: Learning/academic delays? Yes No Reading level?
School performance:
School behavior:
EMPLOYMENT HISTORY
Currently employed? Yes NoEmployer:
Work performance/issues:
BEHAVIORAL HEALTH/MENTAL STATUS(rating of 4+ requires intervention on MTP or rationale for omission)
Severity: 1=no problem; 2-3=slight problem; 4-6=needs treatment; 7-9=hospitalization may be needed; P=past problem (>3 mo ago)
Depression:sad, withdrawn, flat affect, hopeless, apathetic, lethargic, other:
Anxiety:worries, fearful, phobic, panic, OCD, PTSD symptoms, sleepless, other:
Hyper-manic:inattentive, disruptive, overactive, impulsive, distractible, sleepless, other:
Psychosis:hallucinations, delusions, disoriented, loose associations, other:
Substance use*:alcohol, tobacco, illegal, prescription, binges, cravings, other:
Peer problems:argues, provokes, verbal abuse, physical aggression, rejected, other:
Authority problems:defiant, argues, verbal abuse/cursing, physical aggression, other:
Family conflict: conflict with sibling, parent, child, partner, extended family, other:
Sexuality issues:sexual acting out, sexual preference issues, gender confusion, other:
Self-care problems:poor hygiene, needs assistance, daytime enuresis, encopresis, other:
Antisocial:breaks societal rules, lies, truant, curfew violations, firesetting, theft, other:
Danger to self**: risk-taking, suicidal ideation/plan, self injury, suicide attempt, other:
Danger to others**: violent, causes injury, weapons, homicidal ideation/threats, other:
Sleep issues: resists bedtime, wakes frequently, wakes early, wets bed, other:
Other symptom: Average hours sleep at night:
*Rating of 7+ on substance use requires referral to substance abuse assessment/treatment
**Rating of 7+ on danger to self or danger to others requires a written safety plan/crisis assessment
Details & history of symptoms:
SUICIDE RISK(based on clinical assessment--not to be conducted as a questionnaire)
Passive thoughts (Client wisheshe were…): NonePastCurrentFrequency:
Suicidal desire (Client wants to…): None PastCurrentFrequency:
Suicidal intent (Client is going to…):NonePast Current Recency:
Suicide plan (How client is going to…): NonePastCurrentRecency:
Plan lethality (likelihood of death):NoneLowModerateHigh
Suicide means (Client has access to…): NonePossibleLikelyDefinite
Risk Factors:NONEsocially isolatedrecent/impending lossactively psychotic
poor parent-child communicationblames self for negative eventsgender identity struggles
previous suicide gesture/attempt other self-destructive behaviorfamily history of suicide
chronic/painful medical conditionhistory of physical/sexual abusepsychiatric hospitalization
Assessed suicide risk: Low Moderate (on MTP)High (safety plan)Immediate (call 911)
Details:

MENTAL HEALTH TREATMENT HISTORY(include treatment type, provider/agency name, dates of treatment)

Outpatient:
Inpatient/crisis unit:
Current psychotropic medications/dosages:
Results/side effects of current medications:
Prior medications/results/side effects:
Prior diagnoses:
Family mental health, substance abuse issues:
Client has psychiatric advance directive? Yes No (if yes, attach a copy of written advance directive)
Additional information:
INTERPRETIVE SUMMARY (include significant findings in all areas, relationship between issues, factors affecting outcome)
INITIAL TREATMENT PLAN
Client statement of presenting issues:
Client/family goals in treatment:
Religious/cultural sensitive issues:
Gender sensitive issues:
Current services/social supports:
Service recommendations/support needs:
Client willingness to participate:
Caregiver willingness to participate:
Other preferences:
PROVISIONAL DIAGNOSES (Clinical Impressions)

Axis I:ICD-9:

ICD-9:

Axis II:ICD-9:
Axis III:Axis V: GAF:
Axis IV:
Discussion of Diagnoses with Licensed Supervisor:Date:

I agree with the treatment recommendations and provisional diagnoses contained in this evaluation.

______

Primary Clinician/CredentialsDate CompletedLicensed Supervisor/CredentialsDate Discussed

Revised 10/13