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Biopsychosocial Assessment
First name
*
Address
Birth Date
Month
Day
Year
Email
*
Phone
Reason for Seeking Care
What brings you to therapy?
What goals do you have for therapy?
Are you seeking a psychiatric/medication evaluation?
Yes
No
Current Symptoms
In the past 30 days, have you experienced any of the following? (Check all that apply)
Angry
Anxious
Avoidant of crowds
Difficulty concentrating
Difficulty sleeping
Compulsive behavior
Depressed
Disturbing thoughts
Appetite or eating changes
Fearful
Feelings of worthlessness
Grief or sadness
Guilt
Hallucinations (hearing or seeing things)
Hopelessness
Identity concerns
Impulsivity
Low confidence
Lack of interest
Nervousness
Obsessive thoughts
Overwhelm
Panic attacks
Paranoia or suspiciousness
Poor memory
Preference for isolation
Nightmares
Relationship difficulties
Restlessness
Self-harming behavior
Sleep too little
Sleep too much
Substance use
Rapid or pressured speech
Fatigue
Other (please describe):
Trauma History
Have you experienced trauma (e.g., abuse, violence, accidents, loss)?
Yes
No
If yes, please briefly describe (optional):
Substance Use
Do you regularly use tobacco or nicotine products?
Yes
No
Have you or others been concerned about your use of the following?
Alcohol
Prescription medications
Recreational drugs
Behavioral addictions (e.g., gambling, pornography, shopping)
If yes, please describe:
Family history of addiction?
Yes
No
Personal, Family, and Social History
How would you describe your relationships with family members?
How would you describe your relationships with friends, classmates, or colleagues?
Have you had past difficulties in your support system?
Relationship status:
Have you experienced challenges in current or past romantic relationships?
Anything else you'd like to share about your personal or social relationships?
Education
Highest level of education completed:
Would you describe your schooling experience as positive overall?
Yes
No
Are you currently enrolled in school or a training program?
Yes
No
Occupational History
What is your current occupation?
How long do you typically stay in a job before changing roles?
Weeks
Months
About a year
More than a year
Military status:
Never served
Active
Retired
Reserves
Other
Medical History
Do you have current physical health conditions that affect your daily functioning or mental health?
Mental Health History
Have you received mental health services in the past?
Yes
No
If yes :- What was the focus of that treatment?
Why did the treatment end or change?
Have you ever received a mental health diagnosis?
Yes
No
Have you taken psychiatric medication in the past?
Yes
No
If yes, what diagnosis?
If yes, what medication(s)?
Side effects or adverse reactions?
Have you ever been hospitalized for psychiatric reasons?
Yes
No
If yes, please explain:
Have you participated in an Intensive Outpatient Program (IOP) or Partial Hospitalization Program (PHP)?
Yes
No
Have you attended any self-help or peer support groups?
Yes
No
If yes, please describe:
Additional Information
Is there anything else you'd like your therapist to know?
Submit
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