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BiopsychosocialAssessmentInitialIntake.docx
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Initial Assessment—Adult

Client’s name:

Date:

Starting time:

Ending time:

Duration:

PART A. BIOPSYCHOSOCIAL ASSESSMENT

1. Presenting Problem

2. Signs and Symptoms . . . Resulting in Impairment(s)

(Include current examples for treatment planning, e.g., social, occupational, affective, cognitive, physical)

3. History of Presenting Problem

Events, precipitating factors, or incidents leading to need for services:

Frequency/duration/severity/cycling of symptoms:

Was there a clear time when Sx worsened? Family mental health history:

4. Current Family and Significant Relationships (See Personal History Form) Strengths/support: Stressors/problems: Recent changes: Changes desired: Comment on family circumstances:

5. Childhood/Adolescent History (See Personal History Form)

(Developmental milestones, past behavioral concerns, environment, abuse, school, social, mental health)

6. Social Relationships (See Personal History Form) Strengths/support: Stressors/problems: Recent changes: Changes desired:

7. Cultural/Ethnic (See Personal History Form)

Strengths/support: Stressors/problems: Beliefs/practices to incorporate into therapy:

8. Spiritual/Religious (See Personal History Form) Strengths/support: Stressors/problems: Beliefs/practices to incorporate into therapy: Recent changes: Changes desired:

9. Legal (See Personal History Form)

Status/impact/stressors:

10. Education (See Personal History Form)

Strengths: Weaknessess:

11. Employment/Vocational (See Personal History Form) Strengths/support: Stressors/problems:

12. Military (See Personal History Form)

Current impact:

13. Leisure/Recreational (See Personal History Form) Strengths/support: Recent changes: Changes desired:

14. Physical Health (See Personal History Form)

Physical factors affecting mental condition:

15. Chemical Use History (See Personal History Form)

Patient’s perception of problem:

16. Counseling/Prior Treatment History (See Personal History Form)

Benefits of previous treatment: Setbacks of previous treatment:

PART B. DIAGNOSTIC INTERVIEW

Mood (Rule in and rule out signs and symptoms: validate with DSM V, as appropriate)

Predominant mood during interview:

Current Concerns (give examples of impairments (i), severity (s), frequency (f), duration (d))

_________________________________________________________________________________

_________________________________________________________________________________

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Mental Status

(Check appropriate level of impairment: N/A or OK signifies no known impairment.

Comment on significant areas of impairment.)

Appearance

N/A or OK

Slight

Moderate

Severe

Unkempt, disheveled

( )

( )

( )

( )

Clothing, dirty, atypical

( )

( )

( )

( )

Odd phys. characteristics

( )

( )

( )

( )

Body odor

( )

( )

( )

( )

Appears unhealthy

( )

( )

( )

( )

Posture

N/A or OK

Slight

Moderate

Severe

Slumped

( )

( )

( )

( )

Rigid, tense

( )

( )

( )

( )

Body Movements

N/A or OK

Slight

Moderate

Severe

Accelerated, quick

( )

( )

( )

( )

Decreased, slowed

( )

( )

( )

( )

Restlessness, fidgety

( )

( )

( )

( )

Atypical, unusual

( )

( )

( )

( )

Speech

N/A or OK

Slight

Moderate

Severe

Rapid

( )

( )

( )

( )

Slow

( )

( )

( )

( )

Loud

( )

( )

( )

( )

Soft

( )

( )

( )

( )

Mute

( )

( )

( )

( )

Atypical (e.g., slurring)

( )

( )

( )

( )

Attitude

N/A or OK

Slight

Moderate

Severe

Domineering, controlling

( )

( )

( )

( )

Submissive, dependent

( )

( )

( )

( )

Hostile, challenging

( )

( )

( )

( )

Guarded, suspicious

( )

( )

( )

( )

Uncooperative

( )

( )

( )

( )

Affect

N/A or OK

Slight

Moderate

Severe

Inappropriate to thought

( )

( )

( )

( )

Increased lability

( )

( )

( )

( )

Blunted, dull, flat

( )

( )

( )

( )

Euphoria, elation

( )

( )

( )

( )

Anger, hostility

( )

( )

( )

( )

Depression, sadness

( )

( )

( )

( )

Anxiety

( )

( )

( )

( )

Irritability

( )

( )

( )

( )

Perception

N/A or OK

Slight

Moderate

Severe

Illusions

( )

( )

( )

( )

Auditory hallucinations

( )

( )

( )

( )

Visual hallucinations

( )

( )

( )

( )

Other hallucinations

( )

( )

( )

( )

Cognitive

N/A or OK

Slight

Moderate

Severe

Alertness

( )

( )

( )

( )

Attention span, distractibility

( )

( )

( )

( )

Short-term memory

( )

( )

( )

( )

Long-term memory

( )

( )

( )

( )

Judgment

N/A or OK

Slight

Moderate

Severe

Decision making

( )

( )

( )

( )

Impulsivity

( )

( )

( )

( )

Thought Content

N/A or OK

Slight

Moderate

Severe

Obsessions/compulsions

( )

( )

( )

( )

Phobic

( )

( )

( )

( )

Depersonalization

( )

( )

( )

( )

Suicidal ideation

( )

( )

( )

( )

Homicidal ideation

( )

( )

( )

( )

Delusions

( )

( )

( )

( )

Estimated level of intelligence: Orientation: Time Place Person

Able to hold normal conversation? Yes No

Eye contact: Level of insight:

Complete denial Slight awareness

Blames others Blames self

Intellectual insight, but few changes likely

Emotional insight, understanding, change can occur

Client’s view of actions needed to change:

Comments

PART C. DIAGNOSIS VALIDATION

Diagnosis 1:

Code:

Examples of impairment:

Additional validation (e.g., testing, previous records, self-report):

Diagnosis 2:

Code:

Examples of impairment:

Additional validation (e.g., testing, previous records, self-report):

Diagnosis 3:

Code:

Examples of impairment:

Additional validation (e.g., testing, previous records, self-report):

Prognosis: Poor Marginal Guarded Moderate Good Excellent

Qualifiers to prognosis: Med compliance Tx compliance Home environment

Activity changes Behavioral changes Attitudinal changes Education/training

Other:

Treatment Considerations

Is the patient appropriate for treatment? Yes No

If no, explain and indicate referral made: Tx modality: Indiv. Conjoint Family Collateral Group

Frequency:

If Conjoint, Family, or Collateral, specify with whom:

Adjunctive Services Needed:

Physical exam School records

Laboratory tests (specify):

Patient records (specify):

Therapist’s Questions/Concerns/Comments: Psychiatric evaluation Psychological testing

Therapist’s signature/credentials:

Supervisor’s Remarks

Date: / /

Supervisor’s signature/credentials:

Therapist’s Response to Supervisor’s Remarks

Date: / /

Therapist’s signature/credentials: Date: / /