BIOPSYCHOSOCIAL ASSESSMENT

Client: [Name, age, pronouns]
Date: [Date of assessment]
Sources of information: [Client, family, records, other providers, with consent]
Referral question: [Who referred the client, and what they asked]
Clinician: [Name, credentials]

PRESENTING CONCERNS
Concerns: [In the client's words, and the family's if they took part]
Course: [Onset, how it has changed, what has been tried]

BIOLOGICAL
Physical health: [Medical conditions, pain, disability, recent illness or injury]
Medications: [Name, dose, adherence, side effects that affect mood or sleep]
Sleep, appetite, and energy: [Patterns, recent changes, weight change]
Substances: [Alcohol, nicotine, cannabis, caffeine, other drugs]
Family health history: [Medical and psychiatric conditions in close relatives]
Development: [For children and adolescents: pregnancy, birth, milestones, puberty]

PSYCHOLOGICAL
Current symptoms: [Mood, anxiety, trauma responses, psychosis, other]
Mental health history: [Past diagnoses, treatment, and what helped]
Beliefs and coping: [How the client sees self and problem; coping styles; emotion regulation]
Presentation: [Brief mental status observations]
Measures: [Scales used, with scores]

SOCIAL
Household and housing: [Who the client lives with; housing stability]
Relationships and support: [Partner, family, friends, isolation]
School or work: [Role, performance, recent changes]
Finances and legal: [Money stress, legal involvement]
Adverse experiences: [Trauma, loss, discrimination, asked in general terms]

CULTURE AND SPIRITUALITY
Identity and language: [Cultural background, preferred language, values the client names]
Explanation of the problem: [How the client and family understand it, and their views on help]
Faith and meaning: [Spiritual or religious practice, sources of meaning]

STRENGTHS AND PROTECTIVE FACTORS
Strengths: [Skills, interests, values, past successes]
Protective factors: [People, communities, reasons for living, engagement in care]

RISK
Risk to self: [Suicidal ideation, self-harm, past attempts, access to means]
Risk to and from others: [Violence, abuse, neglect, safety at home]
Risk summary: [Current level of concern, the reasons, and any safety plan]

FORMULATION
Integrated summary: [How biological, psychological, and social factors interact to start and maintain the problem]
Working diagnosis: [Diagnosis or impression, if any]

RECOMMENDATIONS
Treatment: [Approach, frequency, and focus]
Referrals and coordination: [Medical, psychiatric, school, or community services, with consent]
Next steps: [Who does what, by when]

Signed: [Clinician name, credentials, date and time]