Wendy Lewis 3

CNL-605: Biopsychosocial Assessment Template

Client’s Name:	Date:
DOB:	Age:
Start Time:	End Time:

Identifying Information:

Presenting Problem/Chief Complaint:

Substance Use History:

Addictions (i.e., gambling, pornography, video gaming):

Medical History/Mental Health History/Hospitalizations:

Abuse/Trauma History:

Social History and Resources:

Legal History:

Educational History:

Family History:

Cultural Factors:

Resources, Strengths, and Weaknesses:

Case Conceptualization (Conceptualize the case using your preferred theoretical orientation):

Clinical Justification:

Initial Diagnosis (DSM-5):

Principal Diagnosis:	ICD-10 Code:	DSM-5 Disorder:	Subtypes:	Specifiers:
Provisional Diagnosis:	ICD-10 Code:	DSM-5 Disorder:	Subtypes:	Specifiers:

Initial Treatment Goals Informed by Theoretical Orientation (SMART Goal Format):

Goal # 1:
Objectives:	Interventions:	Target Date:
1.
2.
Goal # 2:
Objectives:	Interventions:	Target Date:
1.
2.

Student Clinician’s Name:

Date: