Bio-Psych-Soc Questionnaire

The following is a very intense look at the experiences in your life. There may be areas you prefer not to answer because of personal reasons. You always have the right not to provide an answer if you prefer. Please know that this decision may complicate the therapeutic process but is and will always be your decision to make. If you would prefer not to answer a question for personal reasons, please note it with “prefer not to answer” or “prefer to discuss”.

Demographics

First name

Middle name

Last name

Ethnicity

Phone

Email

Alias name(s) if applicable

Date of birth

Gender

Address

Diagnosis/Problems

ICD-10/DSM-V Code	Diagnosis Impression	Primary	Date

Family History

Name(parents/siblings)	Age	Occupation	Quality of relationship

Parents are married: Yes	No	If no, please explain briefly:

Client: Married Divorced Never Married Dating

The following people live in the home with the client:

Family medical history:

Family psychiatric history:

Family history of drug/alcohol abuse:

Other family stressors:

Family Dynamics

Communication styles in the home(passive, aggressive, assertive, loud, quiet, etc.):

Family nurturing patterns:

Family strengths:

Family weaknesses:

Community resources and support utilized by the family:

Developmental History

Pregnancy complications if any:

Illness in the first year of life if any:

Developmental milestone challenges(rolling over, crawling, walking, talking, potty training, etc.):

Nutrition/Nourishment Assessment

Weight change in the previous 6 months:

Please explain the change if any:

Eating pattern changes in the past 6 months:

History of eating disorder Yes No If yes, please explain:

Hours of sleep per night typically:

Changes in sleeping pattern during the last 90 days(please note nightmares, difficulty falling asleep, difficulty waking up, challenges staying asleep, etc):

Number of hours exercising per week typically:

Changes in exercise pattern during the last 90 days:

Mindfulness practices used(list things like mindful breathing, yoga, 5 senses work, etc):

Is internal dialogue primarily positive or negative?	Positive Negative	Explain:

Religious/spiritual changes in the past 90 days:

Mental Health

Previous mental health diagnosis:

Current relational challenges:

Current support systems:

Current pressures on relationships:

Current pressures at work:

Current pressures at school:

Current cultural pressures(media, political, religious, economic, etc):

History of fire setting: Yes No	Explain(how often and to what extent):

History of cruelty to animals: Yes No	Explain(how often and to what extent):

History of isolation: Yes No	Explain(how often and to what extent):

History of running away: Yes No	Explain(how often and to what extent):

History of self harm: Yes No	Explain(how often and to what extent):

History of hospitalization for mental health reasons: Yes No Explain(how often and to what extent):

Describe the confidence or lack of confidence:

Anticipated challenges in the next 90 days:

Suicidality

Frequency(number of attempts total):

Frequency of suicidal thoughts: Never Less than once a year More than once a month More than once a week More than once a day

Starting with the most recent suicidal attempt, list all attempts:

Date(most recent to the first attempt)	Method(pills, driving, hanging, etc)	Intensity from 0-10 with 10 representing an attempt with a high risk of completion	Result(hospitalized, someone intervened, stopped myself, etc)

If there were more than this, please list them here:

Trauma(Date and explanation for each event)

History of Sexual abuse:

History of physical abuse:

History of emotionally traumatic experiences(car accidents, bullying and/or any significant moments of powerlessness):

Sexual Development

Age of first sexual experience:

Total number of sexual partners:

Explain physical and emotional safety practices(protection, relationship rules in place, etc):

Age of exposure to pornography:

Explain history and use of pornography:

Medical History

Current medications:

Medication name	Date started	Amount taken	Frequency	Purpose

Previous medications(medication name, date range it was taken, amount taken, frequency and what it was for):

Medication name	Date started	Amount taken	Frequency	Purpose

Substance Use History

Drug(s) of choice:

Complete history:

Drug name(alcohol, nicotine, marijuana, xanax, oxycodone, etc.)
Days used in the last 30 days
Route of use(smoke, eat, inject, etc.)
Quantity used each time
Date of last use
Age at 1st use
Method of acquiring substance
Pattern of use(daily, weekends, evenings, morning, etc)

Impacts of drug use on different aspects of life(relationships, school, work, finances, legal, etc):

Legal Status

Arrests(date, reason and ramifications/results):

Pending legal issues:

Probationary status:

Probationary officer(name and contact):

Social Atmosphere

Environment in the home(check all that apply): Calm Chaotic Dangerous Safe Cramped Rural Urban Suburban Trailer House Apartment Loud Quiet Lonely Clean Dirty Organized Messy

Explain the highs and lows of the home environment:

Primary language in the home:

Holidays celebrated:

Socioeconomic status(broke, comfortable, wealthy, in a hardship, etc):

Religious/spiritual affiliation:

History of spiritual path:

Peer relationships:

Number of friends:

Number of social media friends:

Number of acquaintances:

Ease at which friends are made: Very easy Easy Somewhat easy Hard Very hard

Romantic relationship:

Getting involved romantically is Very easy Easy Somewhat easy Hard Very hard

Explain:

List activities done with friends and partners(skiing, movies, etc.):

If involved in school, please describe the social experience:

If involved in school, please describe the fulfillment or lack of fulfillment in the educational experience:

Favorite academic subjects:

If involved in work, please describe the social experience:

If involved in work, please describe the fulfillment or lack of fulfillment in the work experience:

Favorite job held:

Future goals for education:

Future goals for work:

Hobbies and interests not otherwise noted(reading, board games, camping, etc.):

Expectations for Treatment

What would you like to change in your life(please provide at least three things):

What would others like to change in your life(please provide who(parent, partner, spouse, friend, mentor, etc.) and what):

Who:

What:

Who:

What:

Who:

What:

What are your strengths?

What are your needs?

What are your gifts/abilities?

Preferences in treatment(focus on trauma, learn coping skills, use CBT, figure out where issues are coming from, etc.) :

Mental Status Summary

Hygiene WNL(within normal limits) Better than usual Worse than usual

Comments:

Affect Appropriate Anxious Angry Restricted

Comments:

Hallucinations Yes	No Comments:

Movements Typical Fidgety Hyperactive Tics Pacing

Comments:

Mood Typical and congruent Anxious Depressed Angry Euphoric Irritated Confused Fearful Other

Comments:

Speech Typical Loud Pressured Slow Slurred Soft Rapid Incoherent

Comments:

Insight Within typical range Good Poor

Comments:

Oriented Person Place Situation Time

Comments:

Memory Intact Short term impaired Long term impaired Immediate impaired

Comments:

Suicidal ideation Yes No Plan Intent Means Denied Client did not indicate any suicidal ideation and there were no indications of concern during the session

Comments:

Eye contact WNL(within normal limits) Better than usual Worse than usual

Comments:

Facial expressions Typical and congruent Angry Sad Worried Happy Suspicious

Comments:

Thought process WNL(within normal limits) Blocked Abrupt transitions Loose

Comments:

Delusions Yes No

Comments:

Demeanor Typical and congruent Cooperative Guarded Friendly Demanding Worried Seductive Resistive Evasive Arrogant Uncooperative Defensive Boastful Irritable Dramatic Apathetic

Comments:

Attention/Concentration WNL(within normal limits) Better than usual Worse than usual

Comments:

Judgment WNL(within normal limits) Better than usual Worse than usual

Comments:

Clinical Narrative

Client Signature:

Date:

Therapist Signature:

Date:

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*Therapist electronic signature indicates the verification of the content belonging to the client.