Bio Assessment

Biopsychosocial Assessment Guide

Identifying Information

This section should include such information as age, sex, race, religion, marital status, occupation, living situations, etc.  Information should be factual, based on information from the client, collateral contacts, and case records.

Reason for Referral/Presenting Problem

This section should identify the referral source and give a summary of the reason for the referral.  This should include the client's description of the problem for services needed including the duration of the problem and its consequences for the client. Past intervention efforts by an agency for the individual and/or family related to the presenting problem should also be summarized.

In addition, comment on any of the following areas that have been impacted by the presenting problem:

· family situation

· physical and economic environment

· educational occupational issues

· physical health

· relevant cultural, racial, religious, sexual orientation and cohort factors

· current social/sexual emotional relationships

· legal issues

Client and family descriptions and functioning

This section should contain data observed by the worker. Focusing on the first few interviews, include pertinent objective information about:

· the client's physical appearance (dress, grooming, striking features);

· communication styles and abilities or deficits;

· thought processes (memory, intelligence, clarity of thought, mental status, etc.);

· expressive overt behaviors (mannerisms, speech patterns, etc.); and

· reports from professional family (medical, psychological, legal).

· Mental Status Exam (if appropriate).

Relevant history

This section should discuss past history as it relates to the presenting problem. While this section should be as factual as possible, it is the place to present how the specifics of the client's culture, race, religion, sexual orientation for example affect resolution of the presenting problem.

Include applicable information about each of the following major areas or about related areas relevant to your client.  (You are not limited by the outline below.)

Family of Origin History: Family composition; birth order; where and with him whom reared; relationship with parents or guardians; relationships with sibling; abuse or other trauma; significant family events (births, deaths, divorce, separation, moves, etc.) and their effect on the client(s).

Relevant Developmental History: Birth defects or problems around the birth process, developmental milestones including mobility (crawling, walking, coordination); speech; toilet training; eating or sleeping problems; developmental delays or gifted areas. This section is especially important for clients who are children. It is critical to identifying non-western expectations and practices for child rearing and development for clients from diverse backgrounds. Nature of stresses and experiences client has encountered throughout his/her life in relation to ability to handle them; how he or she has solved the tasks of various age levels.

The Family of Creation Interrelationships: Interacting roles within the family (e.g., who makes the decisions, handles the money, disciplines the children, does the marketing); typical family issues (e.g., disagreements, disappointments).

Educational and Occupational History: Level of education attained; school performance; learning problems; difficulties; areas of achievement; peer relationships; skills and training; type of employment and employment history; adequacy of wage earning ability; quality of the performance; relationship with authority figures and coworkers.

Religious (Spiritual) Development: Importance of religion in upbringing; affinity for religious or spiritual thought or activity; involvement in religious activities; positive or negative experiences.

Social Relationships: Size and quality of social network; ability to sustain friendships; attended social role losses or gains; social role performance within the client's cultural context. Historical patterns of familial and social relationships.

Dating/Marital/Sexual: Type and quality of relationships; relevant sexual history; ability to sustain intimate (sexual and nonsexual) contact; significant losses; traumas; conflicts in intimate relationships; way of dealing with losses or conflicts. Currently, where do problems exist and how does the client manage successfully?

Medical Psychological: Health problems, including drug, alcohol or tobacco use or misuse; medications; accidents; disabilities; emotional difficulties including mental illness; psychological reports; hospitalizations; impact on functioning; use of previous counseling help.

Legal: Juvenile or adult contact with legal authorities; type of problem(s); jail or prison sentence; effects of rehabilitation.

Environmental Conditions: urban or rural; indigenous or alien to the neighborhood where he or she lives; economic and class structure of the neighborhood in relation to that of the client; description of the home.

Social Worker Assessment

This section should contain the thoughts and opinion of the treating social worker. It is based on the initial observations and information gathering efforts; however, it takes the observations and information to a new level. Here you integrate your view with an understanding of the client's problem or situation, its underlying causes contributing factors and the prognosis for change.

Summarize your understanding of the client’s presenting situation. To do this, draw upon what is known about the current impasse situation that has led to the presenting situation; the social, cultural, familial, psychological, and economic factors that contribute to creating the problem and/or support solutions to the problem. As appropriate, comments on such factors as:

· Social emotional functioning - ability to express feelings, ability to learn from relationships, predominant mood or emotional pattern (e.g., optimism, pessimism, anxiety, temperament, characteristic traits, overall role performance and social competence, motivation and commitment to treatment).

· Psychological factors - reality testing, impulse control, judgment, insights, memory recall, coping style and problem solving ability, characteristic defense mechanisms, manageable problems. If applicable, include a formal diagnosis (e.g., DSM IV, Global Assessment Scale, etc.)

· Environmental issues and constraints or supports from the family, agency, community that affect the situation and its resolution. What does the environment offer for improved functioning (family, friends, church, school, work, clubs, groups, politics, and leisure time activities).

· Issues related to cultural or other diversity that offer constraints or supports from the family, agency, community that affect the situation and its resolution.

· Strengths and Weaknesses in relation to Needs/Demands/Constraints in which he or she functions (Ego Functioning):

. Capacities and skills

. Activity patterns

. Ways of communicating

. Perceptions of him herself and others

. How energy is invested

. What disturbs or satisfies him or her

. Capacity for empathy and affection

. Affects and moods

. Control vs. impulsivity

. Spontaneity vs. inhibition

. Handling of sexuality and aggressiveness; dependency needs, self-esteem and anxiety

. Attitudes toward authority, peers and others

. Nature of defenses

. Method and ability to solve problems

Conclude the assessment with a statement about the client’s motivation for help, the agency's ability to provide help, and anticipated outcome of services to be provided.

Intervention Plan

This section should map out a realistic intervention strategy to address the range of problems and your assessment of the factors that underlie them. You intervention plan should include:

· Problem(s) chosen for intervention

· Goals and objectives

· How the clients, with the workers help, will achieve these goals

· The worker’s role in these interventions

· The anticipated time-frame (e.g., frequency of meetings, duration of the intervention)

· Potential factors that may affect goal achievement (including client motivation; client willingness to take responsibility for change; client’s personal and cultural resources; and/or personal abilities and limitations; agency resources or limitations; community resources or limitations.

· Method(s) by which goal achievement will be evaluated.