Biopsychosocial Assessment Format
- Identifying Information
- Demographicinformation:age,gender,genderidentity;race/ethnicity;sexualorientation;current employment, marital status; language spoken; socioeconomic status: What entitlements does the client receive (SNAP benefits; food assistance, rental assistance, child support services, career services; assistance with utilities; disability services?)
- Referralinformation:referralsource(selforother),reasonforreferral.Otherprofessionalscurrently involved.
- Presenting Problem
- Historyofthepresentingproblem:Lengthordurationoftheproblem(i.e.,howlonghastheproblem been going on?) What precipitating stressors or events brought on the current problem? What feelings and thoughts have been aroused? How has the client coped so far? Prior attempts to resolve the problem. Who else is involved in the problem? How are they involved? How do they view the problem? How have they reacted? How have they contributed to the problem or solution? Past experiences related to current difficulty. Has something like this ever happened before? If so, how was it handled then? What were the consequences? Previous involvement with social agencies for assistance with the problem. If client is in crisis or considered “high risk” (i.e., in danger of harm to self or others, you should describe and offer a brief assessment of the risk).
SWK 650 – Summer 2021 (Rivera)
- Background History
- Familybackground:descriptionoffamilyoforiginandcurrentfamily.Extentofsupport.Familyperspective on client and client’s perspective on family. Family communication patterns. Family’sinfluence on client and intergenerational factors.
- Socialfunctioning:Arethereanysignificantfriendships,interpersonalrelationships,supportnetwork? Use of community organizations or resources (e.g., as client, member, volunteer)?Hobbies/leisure involvement
- Educationaland/orvocationaltraining:Highestlevelofeducation;Degree/searned;Specialschool/educational talents, challenges, goals
- Employmenthistory:Occupation,workhistory,andcurrentstatus(e.g.,employed,unemployed,full-time, part-time; disability). Special training/skills. History of work habits (timeliness, insubordination, ability to fulfill work duties). Reason(s) for leaving (e.g., terminated; history of terminations; relocated)
- Military history (if applicable): Is client a U.S. Veteran?
- Use and abuse of alcohol or drugs, self and family
- Medicalhistory:birthinformation,illnesses,accidents,surgery,allergies,disabilities,healthproblems in family, nutrition, exercise, sleep
- Mental health history: previous mental health problems and treatment, hospitalizations, outcomeof treatment, family mental health issues.
- Significant events: deaths of significant others, serious losses or traumas, significant lifeachievements
- Legalconcerns(ifapplicable):Immigrantstatus,housing,maritalissues,domesticviolence,parole/probation, DWI’s?
- Cultural background: race/ethnicity, primary language/other languages spoken, significance ofcultural identity, cultural strengths, experiences of discrimination or oppression, migrationexperience and impact of migration on individual and family life cycle.
- Religion: denomination, church membership, extent of involvement, spiritual perspective, specialobservances
- Whatfactors,includingthoughts,behaviors,personalityissues,environmentalcircumstances,psychosocial stressors (e.g., bereavement, domestic violence), vulnerabilities, and needs seem to be contributing to the problem(s)? Please use systems theory with the ecological perspective as a framework when identifying these factors.
- Assess client’s motivation and potential to benefit from intervention
- Recommendations/Proposed Intervention
- Tentative Goals (with measurable objectives and tasks)
- One Short-term
- One Long-term
SWK 650 – Summer 2021 (Rivera)
In this section, provide a diagnosis for the client. In narrative form, defend your diagnoses. Use DSM-5 criteria and your knowledge of the etiology of the conditions to support your choices.
You will need to give very specific details and use the DSM-5 approach to formulating the diagnosis. The paper must include a paragraph of each of the following:
Type of disorder
• Illustrate the key aspects of making a differential diagnosis. • What diagnoses would you rule out and why?
CASE FORMULATION (Clinical Summary, Impressions, and Assessment)
The case formulation is an attempt to bring together a number of important factors and create a summary of the case and its many facets. This is the most important part of the biopsychosocial assessment, as it demonstrates your ability to synthesize all of the information you have collected during the assessment process. It also demonstrates your clinical assessment of the client’s condition, while taking into consideration all of the biological, psychological, and social factors influencing the client’s overall functioning. These factors ought to include history, functional status, and resource information about the client. The mental status and diagnosis should be consistent with the client’s presenting problem and personal history.
This section must also demonstrate your knowledge and application of theory. Specifically, you should demonstrate your knowledge of the strengths-perspective and the ecological perspective (Gray & Zide, Chapter 1) in your understanding of the client. You should cite the course text and 3 peer reviewed journal articles on the topic. For example, if the “client” is diagnosed with Bipolar Disorder, your articles should address practice issues related to Bipolar disorder (e.g., suicide risk in bipolar disorder). Your paper must be written in APA style format.
The clinical summary, impressions, and assessment section should:
• First give a brief, 3-5 sentence summary of what you have already written:
o Theclient’schronologicalageandthedevelopmentalstageandtaskthatisappropriateforthat particular age.
o Identifytheprimaryproblem,need,orconcerntheclientisdealingwithandcontributingfactors. o Also,describethesenseofurgencytheclienthaswiththeproblem/s.
Summarize how the client appeared during the interview/s.
speech, sense of reality, judgment, attitude toward their situation/difficulty.
is right now and how the client is handling the problem emotionally and cognitively.
- Goals and Recommendations for work with the cliento Identifygoalsforworkwithclient.
o Recommendationsforserviceandresources§ Modality (what type of treatment?)
§ Length of time (how many sessions? Long term, short term?) § Next steps
- Note the client’s expectations of service.
- Note your assessment of the client’s motivation for change and likely use of service.