Many insurances require you to write a Biopsychosocial Assessment for new clients. A Biopsychosocial includes information that you gather from intake about the background of the client. You can discover a lot of information which can help you treat the client as a whole person including their biological, psychological and social issues.
Sections in a Biopsychosocial
Different people write a Biopsychosocial different ways. The following are some sections you can include it and how to write each section. I don’t include all these sections and I combine some of them but you want all of this basic information in your assessment.
- Demographics/Identifying Data
- Presenting problem
- History of Presenting Problem
- Substance abuse
- Mental Status
- Assessment/Clinical Impressions
Demographics/Identifying Information – Include identifying information like age, sex, marital status, children, financial status, transportation, who they live with, employment, etc.
Presenting problem – The presenting problem is why they came to see you.
History of Presenting Problem – Include any stressors that contribute to presenting problem, detailed history of treatment, what they have tried in the past, how symptoms have progressed, etc.
Medical – Include current or past medication conditions, medications, dosage, purpose, prescribing physician and allergies. You can include their current health status (good, fair, poor) and information about diet, nicotine and caffeine use, and exercise.
Family – Include information on family of origin, relationship with parents and siblings. You can include family history of mental illness or substance abuse. Note any family members who are deceased, how they died and year of death. Note any history of neglect or abuse.
Social – Include information on social support, friends and the nature of those relationships. Can include school and early childhood relationships
Recreational – Include any interests, hobbies, relaxation or fun activities.
Developmental – Include any developmental delays, milestones and you can include the stage of development from Erikson’s stages of development.
Sexual/Relationship – Include current and past significant relationships, sexual orientation, age of first sexual experience, any sexual abuse, any domestic violence and client’s relationship with any children.
Legal – Include any legal issues, probation and probation officer, current and past arrests and the outcome, any convictions and the outcome. You can include any bankruptcy or lawsuits.
Military – Include whether they have ever been in the military. If they have, what rank, how long they were in it, if they are still in it and what type of discharge.
Education – Include their educational history including if they graduated high school and what year. If they didn’t, why they didn’t graduate. Include any college or trade schools, major and if they finished.
Employment – Include their past and current employment and satisfaction with employment. You can include whether they have any financial difficulties if they are underemployed or unemployed.
Substance abuse – Include any information on substances abused past or present, age of fist use, date of last use, method of use, relapses and if they are in recovery. You can include information on caffeine and nicotine use here or with medical section.
Mental Status – Note whether the client was on time, behavior, attitude, orientation to person, place and time, whether they appear to be stated age, whether they dressed appropriately for the weather and situation, mood, affect, tone of voice, rate of speech, judgment, memory, suicidal or homicidal ideation and any observable symptoms.
Assessment/Clinical Impressions – This is your assessment of the client. You can include presenting problem and underlying problems, your impression of the client, any themes or patterns you were aware of, strengths, weaknesses, cultural issues, motivation, readiness to change, what made help the client be successful, negative factors that may impact treatment, preferred coping mechanism of client, potential support systems, appropriate level of treatment, etc.
Treatment – Include how often they will see you, goals and objectives.
Diagnosis – Include their DSM-IV-TR or DSM 5 diagnosis. You can do this by Axis or include the same information in a paragraph form. See my article on Diagnosis with DSM 5 for more information.
I thought it would be easiest to explain how to write a Biopsychosocial by giving an example of how I write it. This is only a sample and is not based on any client I have ever had. I use the information from the Client History and Information and information observed at intake to write it. Note that my form for the Client History and Information follows the same format as the Biopsychosocial which I believe makes it easier to write. I combine similar sections to make it simpler. I’ve also been using DSM 5 so I didn’t include Axis I to IV or a GAF but I still include the same information. You can include Axises if you want because many people are still using DSM-IV TR.
Demographics – Client is a 32-year-old, married Caucasian female with 2 female children, ages 6 and 9. Client resides with her two children. She separated from her husband 6 months ago. She lives with her 2 children in a home she owns. She has no transportation other than the bus which limits where she can travel. She is affiliated with the Catholic religion.
Presenting problem – Client’s current complaint is feeling “stressed” and “unmotivated.” She presents with symptoms of no appetite, insomnia, and hopelessness. Client is having financial difficulties due to the separation. She is underemployed and is seeking employment.
History of Presenting Problem – Client has experienced mild depression in the past. She reported having symptoms of depression after the loss of her grandmother 5 years ago. She was in therapy at that time and took Zoloft for 2 years. She stopped taking Zoloft when she changed insurance plans and did not want to change providers.
Medical/Developmental – Client is being treated by a PCP for gastrointestinal problems. The only medication she takes is Nexium. She has no other biological issues and reports no history of major illnesses or hospitalizations other than the birth of her children. She has no history of developmental issues in childhood. She is in the Young Adulthood stage of development and is struggling with intimacy vs. isolation due to separation from her husband.
Family/Relationship – Client was raised by her mother and father. She reports close relationships with both parents and two male siblings. Her maternal and paternal grandparents are deceased. She was married at age 22 and separated from her husband 6 months ago. She reports no other significant relationships prior to her marriage.
Social/Recreational – Client has one female friend who she is close to. Her interests include music, art and movies. She spends most of her time caring for her children.
Education/Employment – Client graduated high school and completed one year of college with a major in liberal arts. She is employed part-time at a daycare. She wants full-time employment but has been unable to find it. Financial difficulties due to underemployment are a source of stress for her.
Legal/Military – Client reports no involvement with the criminal justice system. She has no legal custody agreement with her husband. She reports no involvement with Child Protective Services. She has never been in the military.
Substance Abuse – Client reports no history of substance abuse issues.
Mental Status – Client was well dressed and clothing was appropriate to the weather and situation. She was oriented to person, place and time. She was cooperative in answering questions and friendly and personable in her disposition. She seemed to have rapport with counselor. Her mood was depressed and sad, however her affect was smiling and friendly. She seemed to be trying to be strong and hide her feelings. Her rate of speech was normal. Her tone of voice was low, quiet.
She seemed to have good judgement and was logical in her statements but had little insight into her problems. She had good memory of her personal history. Her intelligence was above average. She seemed to have an external locust of control. She often blamed her husband for the problems she is having and does not see her role in her depression. She failed to realize her low-self esteem, negative self-talk and lack of confidence in her ability to adjust contributed to her depression.
Assessment – Client strengths include her relationships with her children and family, the support of her friend and educational background. Her weaknesses include an external locus of control and financial difficulties. She has no cultural issues. She denied any suicidal or homicidal ideation. She is self-motivate to therapy. She seemed willing to trust the counseling process and to take part in therapy. She is considering making changes and is in the contemplative stage of change. Resolving her developmental issues may be important to the process. Changing negative self-talk and developing more support and coping skills could improve depression symptoms.
Treatment – Client would benefit from individual therapy on a weekly basis. Client goals include reducing symptoms of depression and finding meaning in her life. Referral to Psychiatrist to explore medication for depression.
Diagnosis– 296.22 Major Depressive Disorder, single episode, moderate, V62.2 Occupational problems, Gastrointestinal issues, moderate level of functioning, good prognosis.