Escolar Documentos
Profissional Documentos
Cultura Documentos
Biopsychosocial Assessment
Where were you born? ____________________ Where were you raised? _________________________
____________________________________________________________________________________
____________________________________________________________________________________
Were you ever in DCF, foster care, or lived anywhere other than with your family? YES NO
Describe:_______________________________________________________________________
Were there any special circumstances that impacted your childhood (loss, neglect)? YES NO
Describe:_______________________________________________________________________
Mother
Father
Spouse/Partner
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Children
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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Marital Status: □ SNM □ Married □ Divorced □ Separated □ Partnered □ Widowed
____________________________________________________________________________________
How important to you are religious or spiritual matters? □ Not □ Little □ Moderate □ Very
Have you ever experienced abuse? YES NO If yes, please describe including ages:
Physical Abuse:__________________________________________________________________
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EDUCATIONAL AND WORK HISTORY
Job History
Monthly Income
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Leisure and Recreational
Describe special areas of interest or hobbies (e.g. art, books, crafts, physical fitness, church)
HOUSING HISTORY
Are you currently homeless? YES NO When did you become homeless? __________________
Have you ever held your own lease? YES NO When? __________________________
Have you ever stayed in the following places because you had no where else to go?
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With friends or family YES NO
LEGAL HISTORY:
Past Charges
____________________________________________________________________________________
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Medications (not including HIV or psychiatric medications)
____________________________________________________________________________________
Allergies: ____________________________________________________________________________
Last Mammogram
Sexual Health
Are you sexually active? YES NO_ Do you have multiple partners? YES NO
HIV/AIDS
□ HIV Negative □ HIV + (Not AIDS) □ AIDS □ Unknown Date of Dx or last test: ___________________
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Disclosure (including family members): ______________________________________________________
Are children aware? YES NO If yes, are they receiving services? YES NO
Describe: _________________________________________________________
ADDICTION
Have you ever had a problem with shopping? (debt or spent money you did not have) YES NO
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How do you believe your substance use has affected your life? ____________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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____________________________________________________________________________________
What or who has helped you stop or limit your use? ____________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Symptomology
Describe:_______________________________________________________________________
Have you ever had anxiety, excessive worrying, and/or panic attacks? YES NO
Describe:_______________________________________________________________________
Have you ever had elevated mood, excessive energy, irritability? YES NO
Describe: ______________________________________________________________________
Have you ever had obsessions or compulsions that impacted your functioning? YES NO
Describe:_______________________________________________________________________
Have you ever had periods of sadness, crying spells, and/or loss of interest? YES NO
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Describe: ______________________________________________________________________
Current
Psychiatric Medications
Name Dosage Reason Name Dosage Reason
Have you ever taken more than prescribed? YES NO Which one? __________________________
Have you ever taken or been prescribed psychiatric medications in the past? YES NO
List: ___________________________________________________________________________
Risk Assessment
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Describe:_______________________________________________________________________
Describe:_______________________________________________________________________
Describe:_______________________________________________________________________
Describe:_______________________________________________________________________
Describe:_______________________________________________________________________
Describe:_______________________________________________________________________
Describe:_______________________________________________________________________
Describe:_______________________________________________________________________
Describe:_______________________________________________________________________
MENTAL STATUS
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Describe: ________________________________________________________________
Describe: ________________________________________________________________
Describe: ________________________________________________________________
Describe: ________________________________________________________________
Memory: □ Intact □ Distractible □ Poor Short Term □ Poor long term □ Other
Describe: ________________________________________________________________
Describe: ________________________________________________________________
Describe: ________________________________________________________________
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Axis I _______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Axis II _______________________________________________________________________
_______________________________________________________________________
Axis IV _______________________________________________________________________
_______________________________________________________________________
Recommendations
• ______________________________________________________________________
• ______________________________________________________________________
• ______________________________________________________________________
• ______________________________________________________________________
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• ______________________________________________________________________
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