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Biopsychosocial Assessment (Narrative)
1. Identifying Information
The client is a married, 30-year-old White male, who resides in Manhattan, New York City. The
man lives in a vibrant village that is recognized for busy city life and ethnic diversity with his
wife and their two kids who are aged 10 and 12 years.
2. Presenting Problem
The man appears to have a low level of mood, which is perceived to originate from a depressive
disorder, as well as low levels of motivation for activities that used to make him happy. He says
he can barely stay awake at work and barely pay attention to everything he is doing at work,
which has put doubt on his work productivity and efficiency levels.
3. Current Family/Relationship History
Having been in marriage for 15 years, the client enjoys a steady relationship with his wife.
Although they have two kids who are usually supportive of each other, the client says that recent
emotional issues have led to stress in the family.
4. Family of Origin History
The client was brought up by supportive parents in a middle-class household. He says that while
growing up, their family did not report any major trauma or incidences of abuse, which depicted
a very stable family in his upbringing.
5. Medical History
As observed from previous health records, the client is currently managing hypertension and is
under-prescribed medication. While not often, his medical history reveals that, at times,
headaches can surface, and he says that he has not experienced significant changes in his
physical well-being.
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6. Substance Use/Misuse History
The records on misuse history reveal that the client does not have any past records of substance
abuse. However, the client admits that he consumes alcohol occasionally, especially on
weekends during leisure activities. He is classified as a moderate alcohol consumer.
7. Mental Health Services History
The mental health service history of the client reveals that he has not attended to any counselor,
therapist, or psychologist. The history also reveals that he has not encountered any serious
mental health issues that need any serious attention.
8. Assessment of Risk
After performing the risk assessment, the results depict that the client is not likely to harm
himself or others. Notably, responding to the question of whether he ever had thoughts of
committing suicide, the client negated the option, meaning that he is not in a state of suicidal
tendencies.
9. Education/Occupation History
The client's education details show that he holds a degree in business management. His
occupational history indicates that he has been a marketing manager for a period of 10 years.
10. Support System: Current/Past
The current and past support system of the client is mainly his friends and close family members
with whom he gets emotional and mental support. Surprisingly, he claims that he relies solely on
these relationships for guidance and support across all aspects of life.
11. Client Strengths
Despite the pressure that he displays in handling emotions, the client is rather determined and
persistent in executing his responsibilities at work and at home. His proactive approach includes
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seeking assistance and actively engaging in interventions designed to enhance his overall well-
being.
12. Summary of Findings
The assessment showcases a middle-aged man presenting with signs of depression regarding
mood, energy, and work. However, no concern of self-harm was evident, nor harm to other
persons, which can be viewed as a sign of stability for him.
13. Recommended Services
From the assessment, it is thus recommended that the client be referred to a qualified mental
health provider for further assessment to formulate a correct differential diagnosis and treatment
plan. It is thus advisable to make some adjustments that may include taking antidepressant drugs
and undergoing cognitive behavioral therapy (CBT).
